■:'■  C  ><<  '-K  r'r'f  *' 


f  'I 


1 


<'.''" '■£ 


A 


PRACTICAL  TREATISE 


DISEASES  OE  WOMEN 


BY 

T.  GAILLARD  THOMAS,  M.D., 

PROFESSOR  OF  DI5EA3E3  OF  WOMEN  IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS, 

NEW  YORK  J 

PRESIDENT   OF  THF.    AMERICAN    GYNECOLOGICAL    SOCIETY    FOR   1S79  ; 

VICE-PRESIDENT  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE  ; 

SURGEON  TO  THE  NEW  YORK  STATE  WOMAN'S  HOSPITAL  \ 

PRESIDENT  OF  THE  MEDICAL  BOARD  OF  THE  NURSERY  AND  CHILD'S  HOSPITAL,  NEW  YORK  j 

CONSULTING  PHYSICIAN  TO  ST.   MARY'S  HOSPITAL  FOR  WOMEN,  BROOKLYN  J 

HONORARY  FELLOW  OF  THE  OBSTETRICAL  SOCIETY  OF  LONDON  J 

CORRESPONDING  FELLOW  OF  THE  OBSTETRICAL  SOCIETY  OF  BERLIN, 

OF  THE  MEDICAL  SOCIETY  OF  LIMA, 

AND  OF  THE  OBSTETRICAL  SOCIETY  OF  PHILADELPHIA  ; 

HONORARY  MEMBER  OF  THE  SOUTH  CAROLINA  MEDICAL  ASSOCIATION  AND  OF  THE 

LOUISVILLE  OBSTETRICAL  SOCIETY. 


FIFTH    EDITION, 

ENLARGED   AXD  THOROUGHLY   REVISED. 
CONTAINING  TWO  HUNDRED  AND  SIXTY-SIX  ENGRAVINGS  ON  WOOD. 


PHILADELPHIA: 
IIEXRY    C.    LEA'S    SOX    &    CO. 

1880. 


Entered  according  to  Act  of  Congress,  in  the  year  I860,  by 

HENRY    C.    LEA'S    SON    &    CO. 

in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


COLLINS,    PRINTER. 


JOHN    T.    METCALFE,  M.D., 

NEW    YORK. 

My  Dear  Doctor  : 

I  dedicate  to  you  the  fifth  as  I  have  done  the  four  previous  editions 
of  this  work.  If  its  merits  have  grown  with  time  as  steadily  as  our 
friendship  has  done,  I  shall  feel  fully  satisfied  with  the  results  of  my 
labors;  and  if  it  receive  from  my  professional  brethren  only  a  tithe  of 
such  kindness  as  that  for  which  during  a  quarter  of  a  century  I  have 
been  indebted  to  you,  I  shall  be  grateful  indeed. 

Sincerely  your  friend, 

T.  GAILLAKD  THOMAS. 


(iii) 


PREFACE  TO  THE  FIFTH  EDITION. 


Twelve  years  have  elapsed  since  the  publication  of  the  first 
edition  of  this  work.  In  that  time  four  successive  editions 
have  appeared,  and  its  author,  recognizing  the  great  advances 
which  during  that  period  have  been  made  in  gynecology,  fully 
appreciates  the  fact  that  a  text-book  which  aspires  to  meet 
the  demands  of  1880  must  of  necessity  be  very  different  from 
one  which  was  offered  to  supply  those  of  1868.  He  has  devoted 
two  years  of  labor  to  the  endeavor  to  bring  this  edition  to 
the  level  of  the  present  state  of  the  science  of  which  it  treats ; 
with  what  success  the  reader  will  judge. 

That  many  new  views,  newr  methods,  and  newr  remedies 
which  have  of  late  years  been  lauded  in  gynecology  pass 
unmentioned  will  at  once  be  apparent.  The  author's  object  has 
been  to  write  a  practical  work,  not  an  encyclopedia;  to  record 
views  and  methods  which  recommend  themselves  on  account 
of  their  merit,  not  merely  of  their  novelty.  So  rapidly  do  new 
things  present  themselves  in  this  active  department  of  medicine, 
however,  that  it  must  be  stated  that  some  innovations  which 
apparently  possess  merit  have  been  left  unmentioned  because 
sufficient  time  has  not  elapsed  for  their  trial. 

To  the  medical  profession  in  America  the  author  would 
express   his    sincere    thanks   for    numberless   acts   of  kindness, 

(v) 


VI  PREFACE    TO    THE    FIFTH    EDITION. 

encouragement,  and  courtesy,  which  have  stimulated  his  ambi- 
tion to  improve  a  work  which  has  met  their  generous  endorse- 
ment and  lightened  the  labor  which  has  attended  his  efforts. 

The  kindly  reception  of  previous  editions  of  this  work  in 
Europe,  as  evidenced  by  its  translation  into  German,  French, 
Italian,  and  Spanish,  has  given  the  author  sincere  gratification, 
and  he  avails  himself  of  this  opportunity  of  thanking  the 
translators  for  the  very  careful  manner  in  which  they  have 
performed  their  work,  and  the  uniform  courtesy  which  they 
have  shown  to  him. 

Upon  two  points  he  would  ask  the  lenient  judgment  of  his 
readers :  first,  the  mechanical  contrivances  for  the  treatment  of 
flexions  of  the  uterus,  which  should  be  honestly  tried  before 
being  judged;  and  second,  the  diagrams  illustrative  of  the 
perineum  and  its  injuries,  which  to  one  who  has  not  carefully 
considered  the  subject  may  appear  exaggerated. 

For  the  index  of  this  edition,  which  the  author  regards  as  a 
good  type  of  what  an  index  should  be,  he  is  indebted  to  his 
friend  Dr.  S.  Beach  Jones. 

New  Youk, 
294  Fifth  Avenue,  Sept.  26,  1880. 


CONTENTS. 


CHAPTER  I. 

Historical  Sketch  of  Gynecology 


CHAPTER  II. 

The  Etiology  of  Uterine  Disease  .... 

Neglect  of  Exercise  and  Physical  Development     . 
Excessive  Development  of  the  Nervous  System 
Improprieties  of  Dress  ...... 

Imprudence  during  Menstruation  .... 

Imprudence  after  Parturition  ..... 

Non-recognition  or  Neglect  of  Injuries  due  to  Parturition 
Prevention  of  Conception  and  Induction  of  Abortion    . 
Marriage  with  Existing  Uterine  Disease 
Insufficient  Food   ........ 

Habitual  Constipation    ....... 


CHAPTER  III. 

General  Considerations  upon  Uterine  Pathology  and  Treatment 
Prognosis  in  Uterine  Affections       ........ 

Reasons  for  the  Frequency  of  Failure  in  the  Treatment  of  Uterine  Diseases 


PAOF. 

17 


41 
43 
45 
45 

47 
48 
49 
50 
51 
51 
52 


54 
60 
61 


CHAPTER  IV. 

General  Considerations  rroN   some  of  the   most  Important  Therapeutic 

Resources  of  Gynecology 

General  System  of  Diet  and  Exercise    ........ 

Pessaries        ............. 

Precautions  to  he  Observed  in  Operations       ....... 

Vaginal  Injections  ........... 

The  Tampon  ............ 

Means  for  Controlling  Temperature         ........ 


CHAPTER  V. 

Diagnosis  of  the  Diseases  of  the  Female  Genital  Organs 
Rational  Signs  of  these  Diseases     ..... 
Management  of  Patient  during  Physical  Examination 

Means  of  Physical  Diagnosis 

Anaesthesia  ....... 


66 
66 
67 
70 
74 


80 

82 
84 
86 
87 


(  Vii  ) 


Vlll 


CONTENTS. 


PAGE 

Vaginal  Touch 87 

Conjoined  Manipulation,  or  Bimanual  Palpation     ....  88 

Abdominal  Palpation       .........  89 

Abdominal  Palpation  conjoined  with  the  use  of  the  Sound       .         .  90 

Inspection         ...........  90 

Rectal  Touch 91 

Simon's  Method  of  Rectal  Exploration 91 

Vesico-rectal  Exploration         ........  92 

The  Speculum 93 

The  Uterine  Sound  and  Probe 100 

Tents 102 

The  Exploring  Needle      .         .         . 109 

The  Aspirator 109 

The  Microscope         .         .         .         .         .         .         .         .         .         .  110 

Auscultation  and  Percussion  ....;...  Ill 

Recapitulation  of  Means  for  Exploring  Pelvic  Viscera  and  Tissues          .  Ill 


CHAPTER  VI. 

Congenital  and  Infantile  Malformations  of  TnE  Female  Sexual  Organs 
Hypertrophy  .......... 


Absence  and  Rudimentary  Development  of  the  Uterus  and  Ovaries 
Congenital  Misplacement  of  the  Uterus  ..... 

Absence  and  Rudimentary  State  of  the  Ovaries  .... 
Absence  and  Rudimentary  State  of  the  Vagina  .... 
Anomalies  of  Uterine  Development  during  Childhood    . 


112 
114 
115 

119 

119 
119 
119 


CHAPTER  VII. 

Diseases  of  the  Vulva           ..........  121 

Normal  Anatomy  .         .         .         .         .         .         .         .         .         .         .         .121 

Vulvitis 122 

Purulent  Vulvitis 122 

Follicular  Vulvitis            ..........  124 

Cyst  and  Abscess  of  the  Vulvo-vaginal  (Hands 126 

Eruptive  Diseases  of  the  Vulva 128 

Phlegmonous  Inflammation  of  the  Labia  Majora 129 

Rupture  of  the  Bulbs  of  the  Vestibule 130 

Pudendal  Hemorrhage    ..........  130 

Pudendal  Hematocele 131 

Pudendal  Hernia 134 

Hydrocele 136 


CHAPTER  VIII. 


Pruritus  Vulvre 
Hyperaesthesia  of  the  Vulva 
Irritable  Urethral  Caruncle 
Urethral  Venous  Angioma 
Prolapsus  Urethne 
Coccyodynia 


138 
14.") 
147 
150 
150 
151 


CONTENTS. 


IX 


CHAPTER  IX. 
The  Female  Perineum  ;  its  Anatomy,  Physiology,  and  Pathology 


PAOE 

154 


CHAPTER  X. 

Prolapse  op  Vagina,  Bladder,  Rectum,  and  Intestines 
Prolapse  of  the  Vagina  ..... 

Cystocele,  or  Prolapse  of  the  Bladder     . 
Rectocele,  or  Prolapse  of  the  Rectum 
Enterocele,  or  Prolapse  of  the  Intestines 
Treatment  of  Vaginal  Prolapse  and  Hernise 
Colporrhaphy  or  Elytrorrhaphy     .... 


168 
108 
172 
172 
173 
174 
170 


CHAPTER  XL 

Surgical  Means  Adapted  to  Restoration  of  the  Perineal  Body 

Varieties  of  Perineal  Laceration    . 

Time  for  Operation  .... 

Treatment  of  Cases  which  have  Cicatrized 

Operation  for  Partial  Rupture 

Operation  for  Complete  Rupture     . 


182 

18G 
188 
190 
192 

198 


CHAPTER  XII. 


Vaginismus 


203 


CHAPTER  XIII. 


Vaginitis        .... 
Simple  Vaginitis    . 
Specific  Vaginitis  or  Gonorrhoea 
Granular  Vaginitis 


211 
212 
215 

218 


CHAPTER  XIV. 

Atresia  of  the  Genital  Tract  and  Retention  within  it  of  Menstrual  Blood 

and  other  Fluids  .... 
Atresia  of  the  Uterus  .... 
Atresia  of  the  Vagina  .... 
Operative  Procedures     .... 


220 
221 
224 
229 


CHAPTER  XV. 


FlSTUL.E  OF  THE  FEMALE  GENITAL  ORGANS 

Urinary  Fistula 

Vesico-vaginal  Fistula  . 
Urethro-vaginal  Fistula  . 
Vesico-uterine  Fistulas  . 
Vesico-utero-vaginal  Fistula- 


)rgans    .... 

.  233 

.  233 

.  233 

.  234 

.  234 

.  234 

X  CONTENTS. 

PAGE 

Treatment 245 

Cauterization           ...........  245 

Suture 245 

Sims's  Operation       ..........  246 

Simon's  Operation    ..........  252 

Elytroplasty 258 

Closure  of  the  Vagina      ..........  259 

Urinary  Fistula?  requiring  Special  Treatment 261 

Vesico-uterine  Fistulse    ..........  261 

Vesico-utero-vaginal  Fistula? 262 

Fistula?  with  Extensive  Destruction  of  the  Base  of  the  Bladder       .         .  262 

Uretero-uterine  and  Uretero-vaginal  Fistula? 263 

CHAPTER  XVI. 

Fecal  Fistula 265 

Entero-vaginal  Fistula? 267 

Simple  Vaginal  Fistula? 267 

CHAPTER  XVII. 

Acute  Endometritis 268 

CHAPTER  XVIII. 

Chronic  Cervical  Endometritis 275 

CHAPTER  XIX. 

Chronic  Corporeal  Endometritis 290 

Injections  into  the  Uterine  Cavity 301 

CHAPTER  XX. 

Areolar  Hyperplasia  of  the  Uterus — The  so-called  Chronic  Parenchyma- 
tous Metritis          ...........  307 

CHAPTER  XXI. 

Granular  and  Cystic  Degeneration  of  the  Cervix  Uteri     ....  336 

Granular  Degeneration  of  the  Cervix     ........  337 

Cystic  or  Follicular  Defeneration  of  the  Cervix 342 

CHAPTER  XXII. 

Syphilitic  Ulcer  of  the  Cervix  Uteri  ........  344 

CHAPTER  XXIII. 

Uterine  Funoosities      ...........  346 


CONTENTS.  XI 

CHAPTER  XXIV.    ' 

PAOE 

Laceration  of  the  Cervix  Uteri „  352 

Trachelorraphy * 359 

CHAPTER  XXV. 

General  Considerations  upon  Displacements  of  the  Uterus         .         .         .  363 

CHAPTER  XXVI. 

Ascent  and  Descent  of  the  Uterus 381 

Ascent  of  the  Uterus      ...........  3S1 

Descent  or  Prolapsus  of  the  Uterus        ........  381 

Methods  of  Replacing  the  Uterus   .........  394 

Methods  of  Sustaining  the  Uterus           ........  395 

Pessaries        .............  401 

CHAPTER  XXVII. 

Anterior  Displacements  of  the  Uterus         .......  405 

Anteversion  .............  405 

Anteflexion    .............  410 

Treatment  of  Anterior  Displacements    ........  413 

Means  for  Reduction       ...........  413 

Means  for  Retention  of  the  Uterus  in  Position        .         .         .         .         .         .417 

Pessaries        .............  420 

Operation  for  Irreducible  Cervical,  Corporeal,  or  Cervico-corporeal  Flexion    .  429 

CHAPTER  XXVIII. 

Posterior  Displacements  of  the  Uterus 432 

Retroversion  and  Retroflexion        .........  432 

Methods  of  Reduction 43S 

Means  for  Retaining  the  Uterus  in  Position    .......  442 

Pessaries 445 

Lateroflexion           ............  452 

CHAPTER  XXIX. 

Inversion  of  the  Uterus 453 

Methods  of  Checking  Hemorrhage,  the  Uterus  being  left  in  situ      .         .         .  402 

Methods  of  Replacing  the  Uterus  .........  463 

Gradual  Reduction          ...........  465 

Rapid  Reduction 467 

Methods  of  Amputating  the  Uterus         ........  471 

CHAPTER  XXX. 

Peri-Uterine  Cellulitis         ..........  475 


Xll 


CONTENTS. 


CHAPTER  XXXI. 

PAGE 

Pelvic  Peritonitis 487 

CHAPTER  XXXII. 

Pelvic  Abscess 502 

Methods  of  Operating 507 

Means  for  causing  closure  of  the  sac      ........  508 

CHAPTER  XXXIII. 

Pelvic  Hematocele 509 

Methods  of  Operating     .         .         .         .         -         .         .         .         .         .         .518 

CHAPTER  XXXIV. 

Myo-Fibromata  or  Fibroid  Tumors  of  the  Uterus 519 

Palliative  Treatment 528 

Curative  Medicinal  Means      ..........  529 

Curative  Surgical  Procedures          .........  532 

Laparotomy   .............  545 

Methods  of  removal  of  the  Uterus 548 


CHAPTER  XXXV. 

Cvsto-fibromata,  or  Fibro-cystic  Tumors  of  the  Uterus 


551 


CHAPTER  XXXVI. 

Uterine  Polypi 558 

Palliative  Treatment •         .         .         .         .  563 

Curative  Treatment        ...........  503 

CHAPTER  XXXVII. 

Sarcoma  and  Adenoma  of  the  Uterus 566 

Sarcoma 566 

Adenoma        .............  570 

CHAPTER  XXXVIII. 


Cancer  of  the  Uterus 

.     571 

Schirrous  Cancer    ........ 

.     575 

Encephaloid  Cancer        ....... 

.     576 

Epithelial  Cancer  ........ 

.     577 

Surgical  procedures         ....... 

.     592 

CONTENTS. 


Xlll 


CHAPTER  XXXIX. 

PAOK 

Diseases  Resulting  from  Retention  and  Alteration  of  the  Fcetal  Envelopes  602 

Uterine  Moles G02 

Cystic  Degeneration  of  the  Chorion,  or  Uterine  Hydatids        ....  G04 

CHAPTER  XL. 

Dysmenorrhea       ............  606 

Neuralgic  Dysmenorrheas       ..........  009 

Congestive  or  Inflammatory  Dysmenorrhea  .                  .         .         .         .  Gil 

Obstructive  Dysmenorrhoea    ..........  613 

Membranous  Dysmenorrhoea           .         .         .         .         .         .         .         .         .  620 

Ovarian  Dysmenorrhoea          ..........  625 


CHAPTER  XLI. 

Menorrhagia  and  Metrorrhagia  .... 


62S 


Amenorrhea 


CHAPTER  XLIL 


635 


Lei'corrhoja 


CHAPTER  XLIIL 


G42 


Sterility 


CHAPTER  XLIV. 


648 


CHAPTER  XLV. 

Amputation  of  the  Neck  of  the  Uterus         .......  652 

Operation  by  Bistoury  or  Scissors  ........  654 

Operation  by  Ecraseur  ...........  654 

Operation  by  Galvano-Cautery        .         .         .         .         .  .  .  .         .  655 


CHAPTER  XLVI. 


Diseases  of  the  Ovaries 

Absence 

Imperfect  Development 

Atrophy 

Ovarian  Apoplexy 

Displacement 

Ovaritis 

Acute  Ovaritis 
Chronic  Ovaritis 


656 
660 
660 
662 
663 
664 
665 
66G 
669 


XIV  CONTENTS. 

CHAPTER  XLVII. 

PAGE 

Ovarian  Tumors «  672 

Carcinoma 673 

Fibroma  or  Fibrous  Tumor 675 

Cysto-Carcinoma    ............  676 

Cysto-Fibroma  or  Cysto-Sarcoma 677 

Dermoid  Cysts 679 

Colloid  Degeneration 680 

CHAPTER  XLVIII. 

Ovarian  Cysts  and  Cystomata 682 

Cysts  of  the  Broad  Ligaments        .........  696 

Parasitic  or  Hydatid  Cysts 697 

Tubal  Dropsy 697 

Subperitoneal  Cysts 699 

Cysts  connected  with  the  Spinal  Cord 699 

Aspiration      .............  715 

Tapping 716 

CHAPTER  XLIX. 

Ovariotomy 722 

Vaginal  Ovariotomy      ...........  731 

Abdominal  Ovariotomy           ..........  733 

CHAPTER  L. 

Oophorectomy 756 

CHAPTER  LI. 

Diseases  of  the  Fallopian  Tubes 760 

CHAPTER  LII. 

Extra-uterine  Pregnancy 765 

CHAPTER  LI  1 1. 

Chlorosis 778 


LIST   OF   ILLUSTRATIONS. 


Fill. 

1.  Ancient  valvular  specula  (Scultetus) 

2.  Thomas's  dressing  forceps 

3.  Davidson's  syringe  .... 

4.  Vaginal  syringe  nozzle,  with  reverse  current 

5.  Sims's  screw  for  removing  a  tampon 

6.  Thomas's  gynecological  table  . 

7.  Thomas's  gynecological  table  . 
.  8.  Practice  of  conjoined  manipulation  (Sims) 

9.  Fergusson's  speculum      .... 

10.  Thomas's  telescopic  speculum 

11.  disco's  speculum    ..... 

12.  Howard's  modification  of  Cusco's  speculum 

13.  Neugebauer's  speculum  .... 

14.  Sims's  speculum       ..... 

15.  Sims's  depressor      ..... 

16.  Nott's  speculum  closed    .... 

17.  Hunter's  speculum  .... 

18.  Thomas's  modification  of  Sims's  speculum 

19.  Nurse  holding  Sims's  speculum  (Sims)    . 

20.  Position  of  woman  in  examining  with  Sims's  s 

21.  Sounds  of  Simpson  and  Sims  compared    . 

22.  Jenks's  elastic  sound       .... 

23.  A  sponge-tent,  with  thread  passing  through  it 

24.  A  sea-tangle  tent     ..... 

25.  A  tupelo  tent  before  and  after  introduction  and  expansion 

26.  Tenaculum  for  fixing  the  uterus 

27.  Introduction  of  a  tent  (Sims)   . 

28.  Dieulafoy's  aspirator        .... 

29.  Manikin  figure  for  teaching  diagnosis 

30.  Coalescence  of  Mullerian  ducts  in  a  foetal  sheep  (I.  Muller) 

31.  A.  S.,  aged  4  years  and  9  months.     Menstruated  regularly  fr 

of  21  months         ....... 

32.  Bow-shaped  rudiment  of  uterus  (Nega)  . 

33.  Bicorn  uterus  (Schroeder)        ..... 

34.  Unicorn  uterus  (Schroeder)      ..... 

35.  Double  uterus  (from  specimen  in  possession  of  author) 

36.  Divided  uterus  (Kussmaul)     ..... 

37.  Development  of  Graafian  vesicles  (Kuss.  Physiology) 

38.  Follicular  vulvitis  (Huguier)  ..... 

39.  Plexus  of  veins  of  the  vestibule  (Kobelt) 


peculum  (Leblond) 


om  the  age 


r.vciE 

23 

74 

76 

76 

78 

85 

86 

89 

93 

'94 

94 

95 

95 

96 

96 

97 

97 

97 

99 

99 

101 

102 

103 

104 

105 

106 

106 

109 

112 

113 


114 
115 
118 
118 
118 
118 
119 
125 
130 


(XV) 


XVI 


LIST    OF    ILLUSTRATIONS. 


F1U. 

40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 

51. 
52. 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
(i6. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 


76. 
77. 
78. 
79. 
80. 

81. 

83. 

84. 


of  support 


Paquelin's  thermo-cautery 

Diagram  ordinarily  used  for  representing  the  perineum 

Transverse  section  of  vagina    ..... 

Normal  relation  of  the  pelvic  viscera 

Schematic  diagram  of  perineal  body         .         » 

The  same,  perineal  body  removed  .... 

The  perineal  body  destroyed,  the  rectal  wall  descends 

The  perineal  body  destroyed,  both  rectal  and  vesical  walls  descend 

An  elastic  rod  when  bent  yields  towards  its  convex  surface     . 

An  elastic  rod  with  double  curves  yields  in  opposite  directions 

An  elastic  strip,  with  decided  convex  curve  below,  will  very  decidedly 
yield  in  the  direction  of  lower  arrow    . 

Sims's  operation  for  colporrhaphy  (Sims) 

Sims"s  operation.     Shape  of  denudation  and  position  of  uterus 

Emmet's  operation  :  first  step  .... 

Emmet's  operation  :  second  step       .... 

Ovoid  denudation,  with  sutures  passed  . 

Perineal  body  perfect  ;  both  vaginal  walls  sustained 

Perineal  body  removed  by  rupture  ;  both  vaginal  walls  robbed 

Perineum  improperly  repaired 

Thomas's  tooth  forceps     . 

Slightly  curved  scissors  . 

Emmet's  scissors,  sharply  curved     . 

Profile  view  of  perineum 

Schematic  view  of  part  to  be  denuded 

Denudation  for  repair  of  perineum  (Savage)    . 

One  of  the  bleeding  triangles  which  are  to  be  created 

The  two  bleeding  triangles  about  to  be  united 

Shows  surface  denuded  and  sutures  in  position 

Profile  view  of  recently  closed  perineum,  sutures  in  place 

Method  of  securing  the  ends  of  the  sutures  (Emmet) 

Diagram  of  perfect  sphincter   .... 

Sphincter  ruptured,  sutures  passed 

Ends  of  muscle  approximated 

Ends  of  muscle  in  apposition  .... 

Schematic  diagram  showing  the  ruptured  bowel 

Surface  denuded  in  complete  perineal  rupture,  and  first  two 
position        ..... 

Jenks's  operation  of  colpo-perineorrhaphy 

Pubo-eoccygeus  muscle  (Savage) 

Sims's  vaginal  dilator      ..... 

Filiform  papillae  of  the  vagina  (Kilian)    . 

Epithelium  in  all  stages  of  development,  in  simple 
ters  (T.  Smith) 

Uterine  atresia  at  os  externum 

Uterine  atresia  at  os  internum 

Atresia  in  one  half  of  a  double  uterus 

The  vagina  distended  by  blood  from  imperforate  hymen 

Vagina  and  uterus  both  distended  with  blood  in  consequence  of  an  im- 
pervious hymen  ........... 


vaginitis, 


sutures  in 


220  diame 


224 


LIST    OF    ILLUSTRATIONS, 


XVI 1 


imon) 


FIO. 

80.  Varieties  of  urinary  fistula? 

87.  Curved  scissors       ....... 

88.  Bistoury  for  paring  edges  of  fistula 

89.  Paring  the  edges  (Wieland  and  Dubrisay)     . 

90.  Showing  bevelling  of  edges 

91.  Sims's  sponge-holder  with  handle  nine  inches  long 

92.  Needles  held  in  forceps 

93.  Course  of  the  needle       ...... 

94.  Passing  the  needle  (Wieland  and  Dubrisay) 

95.  Twisting  the  sutures      ...... 

90.  Fulcrum  for  supporting  wire  while  it  is  twisted     . 

97.  Fork  with  blunt  points  to  aid  the  passage  of  sutures 

98.  Hook  for  engaging  needle 

99.  Sutures  twisted  (Wieland  and  Dubrisay) 

100.  Sims's  catheter,  old  style 

101.  Sims's  catheter,  new  style 

102.  Simon's  position  for  vesico-vaginal  fistula  (S 

103.  Vivifying  the  edges  of  the  fistula  (Simon) 

104.  Sutures  in  position  (Simon)   .         . 

105.  Obliteration  of  the  vagina  (Simon) 

106.  The  cervix  is  slit  to  expose  the  fistula  above,  and  sutures  are  passed 

107.  Anterior  lip  of  fistula  united  to  anterior  lip  of  cervix  (Simon) 

108.  Anterior  lip  of  fistula  united  to  posterior  lip  of  cervix  (Simon) 

109.  Examination  for  fecal  fistula  ....... 

110.  The  dots  represent  the  site  of  chronic  cervical  endometritis   . 

111.  Villi  of  canal  of  the  cervix  uteri,  covered  by  cylindrical  epithelium  and 

containing  looped  bloodvessels,  one  hundred  diameters  (T.  Smith)    . 

112.  Syringe  for  removing  cervical  mucus 

113.  Rod  eight  or  nine  inches  long,  wrapped  with  cotton 

114.  Budd's  elastic  probe       ...... 

115.  Lente's  silver  caustic  probe    ..... 
110.  Lente's  cup  for  fusing  nitrate  of  silver  . 

117.  Silver  probe  with  cotton  wrapped  around  it  and  thread  attached 

118.  Sims's  curette,  representing  the  angles  at  which  it  may  be  bent 

119.  The  dots  show  the  site  of  corporeal  endometritis     . 

120.  Wylie's  cervical  speculum,  with  probe  passing  through  it 

121.  Molesworth's  double  canula  and  bulb  syringe  for  injecting  the  uterine 

cavity         ........ 

122.  Showing  the  site  of  cervical  hyperplasia 

123.  Showing  the  site  of  corporeal  hyperplasia 

124.  Buttles's  spear-pointed  scarificator 

125.  Hard  rubber  cylinder  for  dry  cupping  the  cervix  uteri 
120.  Cystic  degeneration  of  the  cervix  .... 

127.  Recamier's  curette  .         .    ■ 

128.  Sims's  steel  curette         ...... 

129.  Thomas's  wire  curette    ...... 

130.  Emmet's  curette  forceps  ..... 

131.  Bilateral  laceration  to  vaginal  junction 

132.  Bilateral  laceration  to  vaginal  junction,  with  hyperplasia  of  cervical 

walls     ............ 

B 


I'.vci: 
234 
240 
240 
247 
247 
24S 
249 
241) 
249 
250 
250 
250 
250 
251 
251 
251 
253 
255 
257 
200 
201 
202 
202 
206 
275 

276 

284 
2S5 
286 
287 
287 
28S 
289 
290 
299 

300 
321 
321 
333 
334 
343 
350 
350 
350 
351 
350 

356 


XV111  LIST    OF    ILLUSTRATIONS. 

FIH.  PAGE 

133.  Double  tenaculum  separating  the  flaps  of  a  unilateral  laceration  (Em- 

mot)  ....  357 

134.  Multiple  or  stellate  laceration  of  the  cervix  (Emmet)    ....  357 

135.  Lacerated  cervix  denuded,  and  strip  of  undenuded  surface  left  to  act 

as  a  cervical  canal .  360 

136.  Sutures  passed  after  denudation  of  cervix 361 

137.  Sutures  twisted  and  bent  downwards  against  the  wall  of  the  cervix     .  362 

138.  The  regions  of  the  abdomen  and  their  contents.     Edge  of  costal  carti- 

lages in  dotted  outlines  (Gray) 367 

139.  Normal  position  of  the  uterus        ........  368 

140.  Diagram  representing  the  uterine  axis  in  the  three  degrees  of  prolapsus  383 

141.  Skirt-supporter 397 

142.  Waist  with  buttons  for  support  of  skirts        ......  397 

143.  The  action  of  the  diaphragm,  the  parts  in  normal  condition          .         .  400 

144.  The  action  of  the  diaphragm,  the  parts  deformed  by  tight  and  heavy 

clothing 400 

14").  Cutter's  prolapsus  pessary  in  position 403 

146.  Cutter's  prolapsus  pessary     .........  403 

147.  Thomas's  modification    .         .         .         .         .         .         .         .         .         .  403 

148.  The  degrees  of  anteversion    .........  409 

149.  Anteflexion 411 

150.  Normal  axis  and  the  three  varieties  of  flexion       .         .         .         .         .411 

151.  Elliot's  uterine  repositor 415 

152.  Jennison's  sound  ...........  415 

153.  Ellerslie  Wallace's  spring  tent 416 

154.  Abdominal  pad  of  wood  or  cork 418 

155.  Abdominal  supporter 418 

156.  The  perineal  body  destroyed,  both  rectal  and  vesical  walls  descend      .  419 

157.  Thomas's  anteversion  and  anteflexion  pessary 421 

158.  Thomas's  anteversion  pessary,  with  fixed  projection      ....  421 

159.  Thomas's  anteversion  pessary  as  it  appears  in  the  vagina     .         .         .  422 

160.  The  same  instrument  in  position    ........  422 

161.  The  same  instrument  as  it  appears  on  removal 422 

162.  Thomas's  anteversion  and  anteflexion  pessary 422 

163.  Thomas's  elastic  pessary  for  anterior  displacements      ....  422 

164.  Anteversion  pessary  supporting  uterus           ......  423 

1 65.  Cutter's  T-pessary  for  anterior  displacements        .....  423 

166.  Thomas's  modification  of  Cutter's  pessary      ......  423 

167.  Graily  Hewitt's  anteversion  pessary      .......  424 

168.  Fowler's  pessary  for  anterior  displacements            .....  425 

169.  Anteflexion  pessary  supporting  intra-uterine  stem         ....  428 
17".  Glass  stem  supported  by  disc  pessary    .......  428 

171.  Campbell's  soft-rubber  spring-stem  pessary            .....  429 

172.  Schematic  diagram,  showing  the  creation  of  new  uterine  axis       .         .  430 
17:?.  Sims's  knife 431 

174.  Posterior  section  of  the  cervix  (Sims)   .......  431 

175.  Retroversion  of  the  uterus     .........  433 

176.  Retroflexion 433 

177.  The  degrees  of  retroversion   .........  436 

17b.  Sims's  uterine  repositor           .........  440 


LIST    OF    ILLUSTRATIONS. 


XIX 


no. 

17!'.  The  genu-pectoral  position  ;  showing  its  action  in  retroversion 

180.  The  genu-pectoral  position;  showing  its  .action  in  retroversion 

181.  Uterus  supported  hy  tampon 

182.  Hoffman's  inflated,  soft-rubber  pessary 

183.  Hodge's  closed  lever  pessary 

184.  Albert  Smith's  pessary  .... 

185.  Thomas's  retroflexion  pessary 

186.  Elastic  bulb  pessary 

187.  Meigs's  elastic  ring  pessary   .... 

188.  llurd's  pessary       ...... 

189.  Retroflexed  uterus  in  Hurd's  pessary     . 

190.  Hewitt's  pessary 

191.  Cutter's  pessary     ...... 

192.  Thomas's  modification  of  Cutter's  pessary     . 

193.  Force  applied  to  uterine  body  alone 

194.  Force  simultaneously  applied  to  cervix  and  body 

195.  Retrollexion  pessary  with  cervical  rest 
19(3-  Modification  of  Cutter's  pessary  with  cervical  rest 

197.  Intra-uterine  stem  for  latero-flexion 

198.  Partial  inversion    ...... 

199.  Complete  inversion         ..... 

200.  Polypus 

201.  Inversion        ....... 

202.  Fibrous  polypus     ...... 

203.  Partial  inversion    ...... 

204.  Cup  and  stem  for  making  continuous  pressure  in  r< 

uterus         ....... 

205.  Replacement  of  uterus  by  dilatation  through  abdomen 
20(5.  Rapid  reduction  by  White's  method 

207.  Partially  restored  uterus  sustained  by  closure  of  os  externum  (Emmet) 

208.  Lines  representing  the  roof  of  the  pelvis 

209.  Peritoneal  hematocele  (Barnes) 

210.  Subperitoneal  hematocele  (Emmet) 

211.  Uterine  fibroma.    Oblique  longitudinal  section  of  muscular  cell-bui 

(Billroth) 

212.  Molesworth's  cervical  dilators 

213.  Incision  of  cervix  by  Paquelin's  knife  for  the  accomplishment  of 

tation         ....... 

214.  Aveling's  polyptome      ..... 

215.  Nelaton's  forceps   ...... 

216.  The  ecraseur,  straight  and  curved 

217.  The  ecraseur  at  work     ..... 

218.  The  spoon-saw        ...... 

219.  Elastic,  flat,  whalebone  probe 

220.  Attachment  of  fibroid  in  Mrs.  A.'s  case 

221.  Diagram  representing  the  tumor  imbedded  in  the 

uterus         ....... 

222.  Thomas's  clamp,  open   ..... 

223.  Thomas's  clamp,  closed  .... 

224.  The  fibre  cell  characteristic  of  libro-cystic  tumors  (Atlee) 


eplacing  the  in 


posterior  wall  of  the 


erted 


ndles 


dila- 


PABB 

441 
441 
443 
444 
445 
446 
446 
447 
447 
447 
447 
448 
449 
449 
450 
450 
451 
451 
452 
453 
453 
459 
459 
460 
460 

465 
470 
471 
472 
490 
513 
513 

522 
534 

535 
535 
535 
536 
536 
539 
540 
542 

543 
550 
550 
556 


XX 


LIST    OF    ILLUSTRATIONS, 


polypi 


no. 

225.  Cellular  polypus 

226.  Glandular  polypus 

227.  A  submucous  fibroid  being  gradually  transformed  intoa fibrous 

228.  Simpson's  polyptome 

229.  Hicks's  wire  rope  ecraseur     ....... 

230.  Cancer  of  mamma  ;  stroma  and  cells  (Billroth)     . 

231.  Connective  tissue  framework  of  cancer  of  mamma.    Brushed-out  alcohol 

preparation  (Billroth)        .... 

232.  Flat  epithelial  cancer  of  cheek.     Glandular  ingrowth  of  rete  Malpighii 

into  connective  tissue  (Billroth)         .... 

233.  Tranverse  section  of  a  vegetating  epithelioma  (Virchow) 

234.  Vegetating  epithelioma  (Simpson)  .... 

235.  Forceps  for  amputating  the  cervix  .... 

236.  Cervix  amputated  and  parts  above  cut  out    . 

237.  Simon's  scoop  ........ 

238.  Cystic  degeneration  of  chorion  (Boivin  and  Duges) 

239.  Priestly's  dilator  for  the  cervix 

240.  Sehultze's  dilator . 

241.  Simpson's  hysterotome  ...... 

242.  Stohlman's  hysterotome  .         .         .         .  .         . 

243.  White's  hysterotome      ....... 

244.  Dysmenorrhceal  membrane  (Coste)         .... 

245.  Thomas's  wire  curette    ....... 

24o.  Syringe  for  dry  cupping  the  cervix         .... 

247.  Galvanic  pessary    ........ 

248.  Vaginal  leucorrhoea  under  the  microscope  (Smith) 

249.  Cervical  leucorrhoea  under  the  microscope  (Smith) 

250.  Conoidal  cervix  (Sims)  ..... 

251.  Byrne's  galvano-caustic  battery     . 

252.  Microscopic  appearance  of  ovarian  fluid  (Drysdale) 
2.">:J.  Tubal  dropsy  (Hooper)  ..... 

254.  Spencer  Wells's  trocar  ..... 

255.  Spencer  Wells's  trocar  ..... 

256.  Bozeman's  securing  apparatus 

257.  Emmet's  trocar  and  canula  for  tapping  cysts 

258.  Dawson's  temporary  clamp     .... 

259.  Thomas's  clamp     ...... 

260.  Storer's  clamp-shield      ..... 

261.  Thomas's  drainage  tube  of  metal,  vulcanite,  or  glass 

262.  Record  of  temperature  in  a  case  of  ovariotomy 

263.  Record  of  temperature  in  a  case  of  ovariotomy 

264.  Record  of  temperature  in  a  case  of  ovariotomy 

265.  Kibbee's  fever-rot  ..... 

266.  Tubal  dropsy  (Boivin  and  Duges) 


THE 


DISEASES  OF  WOMEN 


CHAPTER    I. 

HISTORICAL  SKETCH  OF  GYNECOLOGY. 

At  the  present  day,  when  so  much  attention  is  being  paid  to  the  diseases 
peculiar  to  women,  it  becomes  almost  necessary  that  a  chapter  upon  the 
history  of  the  subject  should  precede  others  of  a  more  practical  character 
in  a  systematic  work.  A  knowledge  of  what  has  been  accomplished  in 
reference  to  any  subject,  and  what  was  known  concerning  it  in  previous 
ages,  cannot  fail  to  interest  the  student,  and  render  him  more  capable  of 
appreciating  recent  advances.  In  this  way,  too,  a  taste  for  the  study  of 
ancient  literature  may  be  inculcated,  and  many  a  useful  hint,  many  a  sug- 
gestive statement  may  be  met  with  which  will  germinate  for  the  common 
good.  Some  of  the  most  valuable  contributions  to  modern  gynecology  will 
be  found  to  be  foreshadowed,  or  even  plainly  noticed,  by  the  writers  of  a 
past  age,  and  afterwards  entirely  overlooked.  As  examples  may  be  cited, 
the  use  of  the  uterine  sound,  sponge-tents,  dilatation  of  the  constricted  cer- 
vix, and  even  the  speculum  itself.  Indeed,  we  need  not  seek  in  ancient 
literature  for  illustrations  of  this  fact,  for  nowhere  could  a  more  striking 
one  be  found  than  that  of  so  valuable  a  procedure  as  Sims's  operation  for 
vesico-vaginal  fistula  being  fully  described  in  every  detail  in  1834,  and  so 
completely  forgotten  in  twenty  years  as  to  be  accepted  as  entirely  new  at 
the  end  of  that  time. 

There  can  be  no  doubt  that  a  knowledge  of  medicine  was  possessed 
by  the  ancient  Egyptians,  whose  literature  has  only  within  the  last  cen- 
tury been  opened  to  profitable  investigation.  Until  1799,  all  concerning 
it  was  enshrouded  in  darkness.  At  that  time  a  French  engineer,  while 
throwing  up  earthworks  at  Rosetta,  discovered  an  insignificant  looking 
stone,  which  has  since  furnished  the  wanting  key,  its  inscription  being 
written  in  Greek  as  well  as  in  the  ancient  hieroglyphics.  Since  then  valu- 
able papyri  have  been,  thanks  to  the  researches  of  De  Sacy,  Akerblad,  and 
Champollion,  fully  and  satisfactorily  deciphered.  The  data  thus  obtained 
2  (17) 


18  HISTORICAL    SKETCH 

carry  the  knowledge  of  medicine  back  to  a  period  previous  to  3000  years 
before  Christ,  and  evince  an  attempt  at  rational  treatment,  Egyptologists 
declare,  which  surpasses  that  displayed  by  the  early  Greeks.  The  "papy- 
rus of  Berlin,"  the  earliest  record  of  medicine,  is  singularly  free  from 
superstitious  doctrines  and  use  of  charms  in  the  treatment  of  disease, 
which  at  a  later  period  crept  in.  Pliny  informs  us  that  in  the  times  of 
the  Ptolemies  a  medical  school  was  established  at  Alexandria,  and  dissec- 
tions of  the  human  body  legalized.  The  Egyptians  appear  to  have  been 
especially  skilful  as  oculists,  and  it  is  probable  that  attention  was  paid  to 
the  diseases  of  women,  for  among  the  six  medical  books  in  the  collection 
Thoth,  consisting  of  forty-two  volumes,  one  devoted  to  this  subject  is 
particularly  mentioned.  Some  modern  Egyptologists  have  even  stated 
that  among  the  hieroglyphics  the  shape  of  the  uterus  can  be  recognized. 
But  Egyptology  is  certainly  to-day  only  in  its  first  infancy.  Hope  that  the 
future  may  bring  forth  a  great  deal  more  than  the  past  has  done  with 
reference  to  it  may  be  further  founded  upon  the  fact  that  Herodotus1 
distinctly  announces  that  specialties  existed  among  this  primeval  people. 
"  Here,"  says  he,  "each  physician  applies  himself  to  one  disease  only,  and 
not  more.  All  places  abound  in  physicians;  some  for  the  eyes,  others  for 
the  head,  others  for  the  teeth,  others  for  the  parts  about  the  belly,  and 
others  for  internal  diseases." 

From  Biblical  literature,  which  is  so  abundantly  at  our  command,  we 
learn  almost  as  little  upon  our  subject;  and  from  the  time  of  Moses, 
about  1500  B.C.,  to  that  of  Hippocrates,  400  B.C.,  testimony  of  pre- 
cise knowledge  upon  it  is  almost  entirely  wanting.  This  is  the  more 
astonishing  when  we  bear  in  mind  that  in  the  Talmud  are  found  evi- 
dences of  a  great  deal  of  knowledge  concerning  the  Csesarean  section  and 
other  subjects  in  obstetrics;  that  in  the  books  of  Moses  we  find  intelligent 
reference  to  the  hymen  and  menstruation ;  and  that  in  the  New  Testa- 
ment we  see  St.  Luke,  a  physician  of  the  time,  recording  the  fact  of  "  a 
woman  having  an  issue  of  blood  twelve  years,  which  had  spent  all  her  liv- 
ing upon  physicians,  neither  could  be  healed  of  any,"  etc. 

Although  we  know  so  little  concerning  the  knowledge  possessed  upon 
this  subject  by  those  who  preceded  the  Greeks  in  civilization,  we  cannot 
doubt  that  they  did  much  to  instruct  the  latter  in  this  as  in  other  depart- 
ments of  learning.  History  everywhere  records  the  fact  that  the  Greeks 
were  instructed  by  the  Egyptians,  as  the  Romans  subsequently  were  by 
the  Greeks. 

With  our  present  knowledge  of  the  literature  of  the  most  ancient  civili- 
zations, we  must  admit  that  with  the  writings  of  the  Greek  school,  founded 
by  Hippocrates,  commences  the  history  of  gynecology.  Three  volumes 
were  written  upon   the    subject  by  authors  contemporaneous  with  Hippo- 

1  Book  ii.  c.  84. 


OF    GYNECOLOGY.  19 

crates.  They  have  ordinarily  been  attributed  to  him,  but  Dr.  Francis 
Adams,  the  translator  of  the  works  of  Hippocrates  for  the  Sydenham 
Society,  declares  them  to  be,  "ancient  but  spurious,  whose  author  is  not 
known."  In  these  books  the  subjects  of  metritis,  induration,  menstrual 
disorders,  displacements,  etc.,  are  discussed.  Aretams,  Galen,  Archigenes, 
and  Celsus,  who  probably  lived  in  the  first  and  second  centuries,  all 
treated  of  gynecology  ;  the  first  describing  the  vaginal  touch,  the  varieties 
of  leucorrhoea,  and  ulceration  of  the  womb:  while  the  second  makes  the 
first  allusion  on  record  to  the  speculum  vaginae,  as  being  a  distinct  instru- 
ment from  the  speculum  ani,  and  the  third  gives  a  description  of  peri- 
uterine cellulitis  which  shows  him  to  have  been  at  least  familiar.with  the 
fact  that  the  tissues  immediately  connected  with  the  uterus  were  liable 
to  suppurative  inflammation,  the  purulent  products  of  which  discharge 
themselves  through  the  vagina  or  rectum. 

Soranus,  the  younger,  made  important  contributions  to  gynecology. 
He  was  educated  at  Alexandria,  and  went  to  Rome  in  the  year  220  B.  C, 
where  he  wrote  his  celebrated  work  De  Utero  et  Pudendo  Muliebri.  He 
is  the  oldest  historian  of  medicine,  and  the  biographer  of  Hippocrates. 
His  accurate  descriptions  of  the  sexual  organs  were  much  admired.  He 
takes  pains  to  assure  his  readers  that  he  dissected  the  human  cadaver,  and 
not  monkeys,  as  did  Galen  and  others.  He  compared  the  form  of  the 
uterus  to  a  cupping-glass,  showed  the  relation  of  this  viscus  to  the  ilium 
and  sacrum,  and  made  known  the  changes  which  the  os  undergoes  during 
pregnancy.  He  attributes  procidentia  to  a  separation  of  the  internal  mem- 
brane of  the  uterus,  speaks  of  the  sympathy  which  exists  between  the 
womb  and  the  mammary  gland,  and  describes  the  hymen  and  clitoris.  He 
understood  digital  exploration  and  the  use  of  the  uterine  sound  and  vaginal 
speculum.  Many  of  the  ancient  writers  confounded  the  uterus  with  the 
vagina ;  he  distinguished  the  one  from  the  other  very  clearly.  Soranus 
likewise  differentiated  pregnancy  from  ascites  and  solid  tumors,  and  laid 
stress  upon  the  absence  of  tympanites  and  fluctuation  in  solid  tumors  as  a 
means  of  distinguishing  them  from  ascites,  in  which  they  are  present. 

From  this  time  for  centuries,  there  is  abundant  evidence  that  the  study 
of  the  subject  was  pursued  with  vigor,  but  so  many  of  the  works  of  the 
authors  of  those  periods  exist  only  in  fragments,  and  so  many  are  strongly 
suspected  of  being  fictitious,  that  we  pass  them  over  to  stop  at  the  faithful 
compilation  of  Aetius,1  who  flourished  at  Alexandria  in  the  sixth  century 
after  Christ.  His  works,  compiled  in  the  great  library  at  Alexandria, 
contain  a  digest  of  what  was  known  and  done  by  his  predecessors  and  con- 
temporaries, and  offer  the  fullest  and  most  reliable  evidence  concerning 

1  I  am  indebted  to  the  library  of  the  New  York  Hospital  for  an  opportunity  of 
fully  consulting  this  and  other  rare  works  which  were  accumulated  by  the  late 
Dr.  John  Watson. 


20  HISTORICAL    SKETCH 

the  knowledge  of  those  times.  In  quoting  him,  and  his  immediate  suc- 
cessor, Paulus  ^Egineta,  who  was  also  a  compiler,  though  a  far  less  con- 
scientious one,  I  must  be  understood  as  recording,  not  the  views  of  these 
individuals,  but  those  entertained  by  physicians  who  lived  from  the  time 
of  Hippocrates  to  the  time  of  their  writing,  a  period  of  about  one  thousand 
years. 

In  his  lGth  book  Aetius  treats  of  the  diseases  of  women  in  such  a 
manner  as  to  leave  no  doubt  as  to  his  having  had  a  thorough  knowledge 
of  many  disorders  and  means  of  investigation  and  treatment,  which,  being 
rediscovered  thirteen  hundred  years  afterwards,  have,  in  many  instances, 
been  regarded  by  us  as  entirely  new.  Thus  he  speaks  of  the  speculum^ 
sponge-tents,  peri-uterine  cellulitis,  medicated  pessaries,  vaginal  injections, 
caustics  for  ulcers  of  the  cervix,  dilatation  of  the  constricted  cervix,  a 
sound  for  replacing  the  uterus,  etc. 

As  I  have  already  stated,  Soranus  before  Christ,  and  Galen  in  the  second 
century,  speak  of  the  speculum  vaginae  ;  but  Aetius  still  more  clearly  men- 
tions it,  and  gives  rules  for  its  introduction,  which  are  copied  almost  ver- 
batim by  Paulus  without  acknowledgment.  The  use  of  sponge-tents  he 
very  fully  describes,  telling  of  their  mode  of  preparation,  and  even  advis- 
ing that  a  thread  should  be  passed  through  them  for  removal,  and  that  a 
succession  of  them  should  be  employed  till  complete  dilatation  is  accom- 
plished.1 The  importance  of  injections,  the  douche,  hip-baths,  and  appli- 
cation of  caustics  for  ulcers  of  the  cervix,  he  also  dwells  upon,  and  advises 
the  dilatation  of  a  constricted  cervix  by  means  of  a  tin  tube.  The  variety 
of  vaginal  injections  in  use  among  the  Greeks  was  as  great  as  that  of 
to-day.  As  astringents,  pomegranate  rind,  galls,  plantain,  rose  oil,  alum, 
sumach,  etc.,  were  employed  ;  and  as  emollients,  linseed,  poppies,  barley, 
etc.,  exactly  as  we  use  them  now.  They  relied  to  a  great  extent  upon  the 
use  of  medicated  pessaries  in  the  cure  of  ulcerations  and  inflammatory 
engorgements,  employing  wool  covered  with  wax,  or  butter  mixed  with 
saffron,  verdigris,  litharge,  etc.  Octavius  Horatianus  even  goes  so  far  as 
to  advise  a  mixture  of  arsenic,  quicklime,  and  sandarach  in  very  foul  ulcers. 
In  addition  to  injections  and  pessaries,  Aetius  mentions  the  use  of  vapor, 
medicated  or  simple,  conducted  to  the  cervix  by  means  of  a  reed  passed 
up  the  vagina. 

The  use  of  a  uterine  sound,  passed  into  the  uterus  and  employed  as  a 
repositor,  is  likewise  alluded  to  by  this  author,  in  a  passage  where  he 
advises  that  displacements  of  the  uterus  should  be  corrected  specillo  et 
digito. 

Paul  of  iEgina,  who  succeeded  Aetius,  alludes  distinctly  to  the  speculum 
as  an  instrument  in  general  use  before  his  time.  "If,  therefore,"  says 
he,  "  the  ulceration  be  within  reach,  it  is  detected  by  the  dioptra ;  but  if 

'  Dr.  II.  G.  Wright,  Med.-Chir.  Rev.,  lxxi. 


OF    GYNECOLOGY.  21 

deep  seated,  by  the  discharges."  And  again,  "  The  person  using  the 
speculum  should  measure  with  a  probe  the  depth  of  the  woman's  vagina, 
lest,  the  tube  of  the  speculum  being  too  long,  it  should  happen  that  the 
uterus  be  pressed  upon." 

It  is  curious  to  see  how,  even  in  many  minor  matters,  the  ancients  an- 
ticipated discoveries  which  our  contemporaries  have  brought  forward  as 
entirely  new.  For  example,  the  air-pessary,  made  so  popular  in  France 
and  other  countries  by  Gariel,  is  described  and  recommended  by  the 
Greeks.  Colombat1  declares  that,  "  The  ancient  Greek  physicians  made 
use  of  pessaries  like  those  just  mentioned  (air  pessaries),  of  the  form 
and  length  of  the  male  organ,  which  is  the  reason  why  they  are- called 
rtptartiux-rwo,  or  priapiform  pessaries."  Albucasis,  in  1104,  describes 
herpes  uterinus ;  and  uterine  hemorrhoids  are  alluded  to  by  Paulus  -<Egi- 
neta2  in  this  explicit  manner :  "  Hemorrhoids  form  about  the  mouth  and 
neck  of  the  uterus,  which  will  be  discovered  by  the  speculum."  And  thus 
it  is  with  so  many  other  modern  suggestions,  that  the  student  of  ancient 
medical  literature  is  most  willing  to  admit  the  truth  of  the  proposition, 
formulated  by  Aristotle  over  two  thousand  years  ago,  that  "  probably  all 
art  and  all  wisdom  have  often  been  already  fully  explored  and  again  quite 
forgotten." 

The  learning  of  the  Greek  School  was  appropriated  by  the  Roman, 
which  was  an  offshoot  from  it,  as  the  writings  of  Celsus,  Aspasia,  Mos- 
chion,  and  Antyllus  abundantly  testify.  But  the  knowledge  of  the  schools 
of  Greece  and  Rome  was  destined  to  be  scattered  abroad.  At  the  period 
of  the  subjugation  of  Egypt  and  the  destruction  of  the  celebrated  library 
at  Alexandria  by  the  Saracens,  A.  D.  640,  it  passed  as  a  trophy  of  war 
into  the  hands  of  the  Moslem  invaders.  "  In  a  few  centuries  the  fanatics 
of  Mohammed  had  altogether  changed  their  appearance,"  says  the  learned 
Draper.3  "  When  the  Arabs  conquered  Egypt,  their  conduct  was  that 
of  bigoted  fanatics  ;  it  justified  the  accusation  made  by  some  against  them, 
that  they  burned  the  Alexandrian  library  for  the  purpose  of  heating  the 
baths.  But  scarcely  were  they  settled  in  their  new  dominion,  when  they 
exhibited  an  extraordinary  change.  At  once  they  became  lovers  and  zeal- 
ous cultivators  of  learning."  The  physicians  of  Alexandria  were  greeted 
by  them  as  instructors,  and  from  the  seed  thus  planted  sprang  the  Arabian 
School.  With  other  information,  of  course,  they  gained  that  pertaining 
to  gynecology,  but,  the  Mohammedan  laws  forbidding  the  examination  of 
women  by  one  of  the  opposite  sex,  the  study  languished  in  their  hands ; 
and  although  Rhazes,  Avicenna,  and  their  successors  copied  from  Greek 
writers  upon   it,  a  want  of  zeal,  due  to  want  of  personal  observation  and 

1  Diseases  of  Females,  Meigs's  translation,  p.  152. 

2  Sydenham  Society's  edition,  vol.  i.  p.  (345. 

3  Intellectual  Development  of  Europe,  p.  285. 


22  HISTORICAL    SKETCH 

experience,  allowed  a  retrograde  movement  to  occur  which  left  the  subject 
enveloped  in  darkness  for  centuries  afterwards.  Albucasis,  one  of  the  last 
of  this  school,  flourished  at  the  end  of  the  eleventh  century,  and  after 
him,  although  from  time  to  time  writers  of  greater  or  less  merit  on  dis- 
eases peculiar  to  women  appeared,  nothing  worthy  of  special  note  occurs, 
except  the  occasional  allusion  to  the  speculum,  which  had  evidently  fallen 
almost  entirely  into  disuse. 

We  have  then  sufficient  data  to  warrant  the  belief  that  the  physicians 
who  flourished  from  the  foundation  of  the  Greek  School  of  Medicine,  400 
years  before  Christ,  to  the  dispersion  of  the  Alexandrian  School  by  the 
Saracens,  640  years  after  Christ,  were  well  informed  in  gynecology,  and 
were  familiar  with  means  of  investigation  which  were  subsequently  lost,  or 
ceased  to  be  appreciated.  They  fully  sustain  the  statement  of  the  English 
translator  of  the  works  of  Hippocrates,  that  "  they  furnish  the  most  indu- 
bitable proof  that  the  obstetrical  art  had  been  cultivated  with  most  extraor- 
dinary ability  at  an  early  period." 

It  must  not,  however,  be  supposed  that  the  knowledge  of  the  ancients 
was  of  the  same  exact  and  scientific  nature  as  that  which  has  prevailed 
since  the  modern  introduction  of  the  speculum.  He  who  seeks  in  this 
literature  for  distinct  and  lucid  pathological  data  will  surely  meet  with 
disappointment.  They  did  not  sufficiently  separate  inflammations  of  the 
puerperal  and  non-puerperal  uterus,  confounded  affections  of  that  organ 
with  those  of  the  pelvic  areolar  tissue,  and  made  no  distinctions  between 
diseases  of  the  mucous  membrane  and  parenchyma,  nor  the  morbid  states 
of  the  neck  and  body.  Among  their  remedies  were  numerous  articles 
which  to-day  we  regard  as  inert  or  even  injurious,  as  pigeon's  dung,  wo- 
man's milk,  stag's  marrow,  etc. ;  and  Aetius  and  Paulus  seem  to  have 
been  as  partial  to  the  "  grease  of  geese"  as  our  lower  classes  are  at  present. 
To  make  amends  for  this  many  a  valuable  and  suggestive  thought  may  be 
gleaned  with  reference  to  diagnosis  and  treatment.  This  has  certainly 
been  proved  by  our  experience  of  the  past,  and  we  have  no  evidence  to 
warrant  the  belief  that  these  rich  mines  have  yet  been  exhausted. 

The  learning  of  the  Arabians  was  in  time,  like  that  of  the  rest  of  the 
world,  gradually  enshrouded  by  the  ignorance  and  superstition  of  the 
period  termed  the  "  Dark  Ages."  During  that  time  many  of  their  writ- 
ings, as  well  as  those  of  the  Greek  and  Roman  schools,  were  destroyed  or 
lost ;  but  as  society  emerged  from  the  darkness  which  overshadowed  its 
intelligence,  we  see  the  thread  at  once  taken  up  and  followed,  though  lan- 
guidly and  without  vigor,  to  the  beginning  of  the  nineteenth  century. 

Toward  the  middle  of  the  seventeenth  century  we  find  very  special  and 
full  allusion  made  to  the  speculum  and  its  uses  by  Ambrose  Pare  and 
Scultetus ;  the  instrument  being  well  represented  by  diagrams,  with  de- 
scriptions attached. 

"  Fig.  1,"  says  Scultetus,  "  is  an  instrument  which  they  call  '  speculum 


OF    GYNECOLOGY. 


23 


ani,  vagina?  et  uteri,'  in  that  by  its  help  ulcers  of  the  rectum,  vagina,  and 
uterus  may  be  seen,  to  be  carefully  observed,  according  to  their  extent 
and  kind." 

Ae'tius  and  Paul  us  evidently  knew  of  a  tubular  speculum,  since  they 
say,  "  lest  the  tube  of  the  speculum  be  too  long,"  etc. ;  but  Scultctus,  as 

Fig.  1. 


Ancient  valvular  specula.  (Scultetus.) 

already  Shown,  figures  a  bi-valve  and  quadri-valve,  closely  resembling 
those  in  our  hands  at  present.  It  is  worthy  of  mention,  in  this  connec- 
tion, that  there  is  now  preserved,  in  the  Museo  Borbonico  at  Naples,  a  bi- 
valve speculum  which  was  removed  from  the  ruins  of  Pompeii. 

It  has  already  been  stated  that  Ae'tius  makes  reference  to  a  sound  for 
replacing  the  uterus.  This  is  by  no  means  the  first  notice  of  this  useful 
instrument,  for  it  is  repeatedly  mentioned  by  Hippocrates.  One  of  six 
passages  from  writings  imputed  to  him,  I  translate  from  the  work  of 
Monsieur  T.  Gallard.1 

"  Treatment  for  rendering  fertile  a  sterile  woman;  attention  is  directed 
to  that  part  which  consists  in  replacing  a  displaced  neck  of  the  uterus. 

"  Just  after  the  patient  has  taken  a  bath  and  a  fumigation,  open  the 
uterine  mouth  and  replace  it  at  the  same  time,  if  necessary,  with  a  sound 
of  tin  or  lead,  at  first  small  in  size,  then  larger,  if  it  passes,  until  the 
difficulty  seems  remedied ;  dip  the  sound  in  any  emollient  preparation 
which  may  be  thought  best,  and  which  should  be  rendered  liquid  by 
melting."2 


1  Lecons  Cliniqnes  sur  les  Maladies  des  Femmes,  p.  115. 

2  Hippocrates  (Euvres  Completes.     Tome  vii.  p.  379. 


24  HISTORICAL    SKETCH 

A  recent  biographer  of  Harvey1  remarks,  "  That  the  older  writers  looked 
upon  the  vagina  and  uterus  as  one  organ,  and  when  they  spoke  of  the 
former,  they  either  called  it  '  uterus'  or  '  cervix  uteri.'  What  we  now  call 
the  cervix  uteri,  they  called  the  internal  cervix ;  and,  as  far  as  my  read- 
ing goes,  no  operative  procedure  upon  this  part  of  the  womb,  when  in  its 
unimpregnated  state,  had  ever  been  attempted  before  Harvey  invented  his 
dilator,  and  used  intra-uterine  injections  of  sulphate  of  iron." 

If  the  passage  recently  quoted  does  not  carry  conviction  that  the  man- 
ipulations recommended  have  reference  to  the  neck  of  the  uterus  and  not 
to  the  vagina,  the  following,  from  the  same  source,  will  do  so : — 

"  Treatment"1  of  cases  in  which  the  seminal  jiuid  is  not  retained  on  ac- 
count of  an  imperfection  of  the  uterine  orifice. 

"  In  those  cases  in  which  seminal  fluid  escapes  immediately  after  inter- 
course, the  cause  is  in  the  mouth  of  the  womb.  They  should  be  treated 
thus  :  if  the  orifice  is  very  much  contracted  it  should  be  dilated  with  small 
bits  of  pine  wood  and  lead."  We  cannot  suppose  that  in  cases  in  which 
intercourse  was  practicable  any  contraction  below  the  os  externum  uteri 
could  exist,  rendering  such  dilatation  necessary. 

Professor  Simpson3  asserts  that  among  the  ancients  the  sound  was  re- 
sorted to  only  for  dilatation  of  the  cervix,  and  not  for  exploration  and 
measurement.  The  specilhan  mentioned  by  Aetius  was  employed  for  re- 
position, while  Hippocrates  advises  the  use  of  a  sound  hollowed  out  on 
one  side,  and  covered  by  medicated  ointments :  this,  "  the  operator  intro- 
duces into  the  uterine  orifice,  and  pushes  onwards  so  as  to  make  it  enter 
the  interior  of  the  uterus.  When  the  medicinal  substance  is  melted,  the 
sound  is  withdrawn."4  In  1657,  a  probe,  used  as  we  now  employ  the 
uterine  sound,  and  intended  especially  for  uterine  exploration,  was  actually 
described  by  Wierus,6  and  alluded  to  by  Hilken,  Cooke,  and  others.  In 
1771  it  was  employed  by  Levret  for  measuring  the  length  of  the  uterine 
cavity  in  hypertrophy  of  the  cervix,  and  subsequently  as  an  aid  to  diag- 
nosis by  Cliambon,  Vigorous,  and  Desormaux. 

As  we  pass  in  review  the  chief  works  which  appeared  upon  our  subject 
in  the  eighteenth  century,  we  find  frequent  mention  of  the  speculum, 
which  is  spoken  of  as  a  matter  of  course  in  the  treatment  of  uterine  affec- 
tions, and  yet  was  evidently  not  so  employed  as  to  render  it  really  a  valu- 
able aid  in  diagnosis  or  treatment.  This  constitutes  one  of  the  mosf 
curious  episodes  met  with  in  the  history  of  any  discovery  with  which 
we  are  acquainted.  A  most  simple  and  useful  instrument  was  not  only 
well  known  in  ancient  times,  and  subsequently  fell  into  disuse,  but  fell 

1  Qbstet.  Journ.  Great  Britain  and  Ireland,  vol.  i.  p.  26. 

2  Gallard,  op.  cit.,  p.  116.  3  Obstet.  Works. 
4  Gallard,  op.  cit.,  p.  116. 

6  Dr.  II.  (}.  Wright,  Diseases  of  Women,  Eng.  ed.,  vol.  i.  p.  135. 


OF    GYNECOLOGY.  25 

into  disuse  without  having  ever  heen  really  forgotten.  It  was  described 
by  successive  writers  up  to  the  nineteenth  century  in  language  as  distinct 
as  words  could  make  it ;  and  yet  not  only  did  tbey  who  read,  but  they 
who  wrote  it,  not  comprehend  its  meaning  or  appreciate  its  significance. 
Like  the  Indians  possessed  of  the  diamond,  all  saw  and  yet  none  valued. 
How  could  Ambrose  Pare,  for  example,  writing  in  1640,  have  indicated 
its  use  more  clearly  than  when  he  tells  us,  in  chapter  xix.,  that  ulcers  of 
the  womb  may  be  recognized,  "  by  the  sight,  or  by  putting  in  a  specu- 
lum f"  In  a  copy  of  his  works,  in  the  library  of  Prof.  W.  A.  Hammond, 
the  word  speculum  is  italicized  in  this  sentence.  Scultetus,  as  we  have 
seen,  not  only  described,  but  figured  the  instrument  in  1G83. 

In  17G1,  Astruc,  "  Royal  Prof,  of  Physic  at  Paris,"  in  describing  oc- 
clusion of  the  vagina  and  obstruction  to  the  menstrual  flow,  says  :  "  There 
is  nothing  more  required  than  to  examine  the  vagina  by  introducing  the 
finger  into  it,  rubbed  previously  with  oil  or  pomatum  ;  but,  if  that  be  not 
sufficient,  a  speculum  uteri  may  be  used,  or  some  other  more  simple  in- 
strument for  dilatation,  in  order  to  be  able,  by  means  of  the  dilatation  of 
the  vagina,  to  judge  by  the  sight  of  what  the  touch  could  not  decide." 

In  1801,  forty  years  after  this,  Recamier  is  supposed  by  many  to  have 
invented  the  speculum.  Most  assuredly  it  was  not  for  the  invention,  but 
for  the  regeneration  of  an  instrument  which  had  been  curiously  lost  sight 
of,  that  the  world  was  indebted  to  this  great  man,  who  was  really  the 
founder  of  the  modern  school  of  gynecology.  Guided  by  the  advice  found 
in  many  works  which  his  library  must  have  contained,  works  with  which 
to  suppose  him  not  to  have  been  perfectly  familiar  would  be  to  cast  a  slur 
upon  his  medical  research,  he  employed  a  speculum  vaginae  in  1801.  Like 
his  predecessors,  he  did  not  appreciate  the  great  results  which  were  to 
flow  from  it ;  nor  does  he  appear  to  have  regarded  himself  as  having  in- 
vented it.  It  was  not  until  1818  that  he  introduced  it  to  the  profession, 
and  gave  if  its  place  as  a  valuable  addition  to  science.  Can  any  one  sup- 
pose that  it  could  have  required  seventeen  years  of  experimentation  and 
study  for  a  man  with  the  talent  of  Recamier,  to  have  applied  this  simple 
and  useful  instrument  to  purposes  of  utility?  Is  it  not  more  likely  that 
the  experience  of  seventeen  years  taught  him  the  full  value  of  the  instru- 
ment ?  The  credit  which  belongs  to  Recamier  is  not  that  of  an  inventor, 
but  that  which  is  equally  great,  of  having  recognized  the  value  of  what 
was  well  known,  but  not  appreciated  by  his  predecessors  and  contempo- 
raries. 

Even  before  this  fortunate  revival,  as  the  eighteenth  century  approached 
its  close,  the  glimmer  of  the  new  era  which  was  about  to  dawn  could 
clearly  be  detected  in  the  advanced  views  which  were  promulgated  by 
Garangeot  and  Astruc  in  France,  and  Denman,  John  Clark,  and  Hamilton 
in  England.  The  early  part  of  the  nineteenth  century  found  the  field 
occupied  chiefly  by  Sir  Charles   Clarke  and  Dr.  Gooch  in  England,  and 


26  HISTORICAL    SKETCH 

Recamier  and  Lisfranc  in  France.  These  were  not  the  only  eminent 
writers  of  that  time,  but  they  were  unquestionably  those  who  chiefly 
moulded  professional  opinion. 

Even  at  that  period  gynecologists  divided  themselves  into  two  parties, 
which  may  be  said  to  have  coalesced  only  within  the  last  decade.  In  Eng- 
land the  feeling  was  strongly  in  favor  of  regarding  the  local  disorder  as 
the  result  and  not  the  cause  of  concomitant  constitutional  derangement ; 
while  in  France  the  uterine  disease  was  viewed  as  the  main  element,  and 
the  general  condition  regarded  as  dependent  upon  and  resulting  from  it. 

The  great  advantages  of  the  speculum  secured  its  rapid  adoption  in 
France.  More  slowly  it  forced  its  way,  in  spite  of  many  prejudices,  in 
Great  Britain,  and  before  a  great  many  years  had  passed,  it  was,  through- 
out the  civilized  world,  placed  upon  an  enduring  basis  as  one  of  the  many 
boons  bestowed  by  medicine  upon  humanity.  The  way  being  opened  for 
investigation  by  this  instrument,  new  aids  to  diagnosis  and  treatment  were 
rapidly  brought  forward.  In  1826,  Guilbert  read  before  the  Academy  of 
Medicine  of  Paris  an  essay  proposing  the  application  of  leeches  to  the 
cervix.  In  1828,  Samuel  Lair  read  before  the  same  body  a  paper  in  which 
he  counselled  the  use  of  the  uterine  sound,  which  had  never  been  utilized. 
In  1832,  M.  Melier  presented  an  essay,  in  which  he  offered  two  new  sug- 
gestions in  the  treatment  of  uterine  diseases — one,  injections  into  the  cavity 
of  the  cervix ;  the  other,  local  applications  through  the  vagina  by  dossils 
of  lint  saturated  with  astringents,  narcotics,  etc.  His  views  are  quoted 
extensively  by  French  writers,  and  Nonat  says  that  the  author  recognizes, 
"  avec  une  franchise  qui  l'honore,"  that  Boyle,  Chaussier,  Guillou,  and 
others  had  a  short  time  before  him  used  similar  means.  Very  curiously 
neither  Melier  nor  his  commentators  mention  that  both  these  suggestions 
are  made  and  fully  elaborated  by  Astruc,  in  his  excellent  article  upon 
"Ulcers  of  the  Uterus."  He  describes  these  applications  of  medicated 
charpie  very  carefully,  remarking  that  it  is  advisable  to  "  tie  a  thread  to 
every  pledget,  in  order  to  draw  it  out  again  when  it  is  proper  to  renew 
the  dressing."  And  he  not  only  advises  injections  of  water,  impregnated 
with  different  substances,  into  the  cavity  of  the  womb,  but  also  the  juices 
of  plantain,  houseleek,  nightshade,  etc.  "  For,"  says  he,  "  as  it  is  of  con- 
sequence that  these  injections  should  enter  into  the  uterus,  where  the  ulcer 
has  its  seat,  it  is  proper  they  should  be  made  by  a  professor  of  midwifery, 
capable  of  introducing  skilfully  the  end  of  the  canula  into  the  orifice  of 
the  uterus,"  etc. 

At  this  time  arose  the  question  as  to  cancer  of  the  uterus,  whether  it 
was  the  local  manifestation  of  a  general  blood  state,  or  the  result  of  an 
inflammatory  engorgement  long  neglected  ;  a  question  which  excited  warm 
discussion,  and  brought  forth  the  most  opposite  views. 

The  ambition  of  Recamier  was  not  satisfied  with  exposing  the  cervix 
uteri  to  view.      lie  had  the  boldness  to  explore  the  cavity  of  the  body  of 


OF    GYNECOLOGY.  27 

the  organ,  almost  establishing  the  use  of  the  sound,  and  even,  by  means 
of  a  species  of  scoop  called  a  curette,  ventured  in  certain  cases  to  scrape 
its  investing  mucous  membrane.  In  addition  he  described,  through  one 
of  his  students,  pelvic  cellulitis,  and  gave  the  first  intimation  which  modern 
observers  have  had  of  the  possibility  of  pelvic  hematocele. 

The  impulse  given  by  Kecamier  to  gynecology  cannot  be  overestimated, 
for  the  instrument  which  he  had  rediscovered,  and  the  merits  of  which  he 
had  appreciated,  was  destined  to  remove  it  from  the  field  of  speculation 
and  theory,  and  to  place  it  in  that  of  exact  science.  From  about  the  year 
1820,  it  began  to  attract  general  attention,  and  to  receive  the  endorsement 
of  the  profession. 

The  subject  at  that  time  received  more  notice  in  France  than  in  any 
other  country,  and  for  the  next  twenty  years  Lisfranc,  Boivin,  Colombat, 
1'IIeritier,  Imbert,  and  others  enriched  its  literature  and  advanced  its  in- 
terests. But  it  was  not  until  towards  the  end  of  that  time  that  any  really 
remarkable  advance  was  effected.  Then  it  was  that  Kiwisch,  in  Germany, 
Huguier,  in  France,  and  Simpson,  in  Great  Britain,  took  the  lead  in  their 
respective  countries. 

It  has  been  already  stated  that  from  the  earliest  period  of  medicine  the 
uterine  sound  had  been  recommended,  and  that  in  the  seventeenth,  the 
eighteenth,  and  the  nineteenth  centuries  this  recommendation  had  been 
repeated.  In  spite  of  this  it  had  never  become  an  instrument  of  practical 
value,  and  even  after  1828,  when  Lair  recommended  it,  it  fell  entirely  out 
of  notice.  By  a  curious  coincidence  Kiwisch,  Simpson,  and  Huguier, 
without  concert  or  communication  with  each  other,  about  the  same  time 
urged  its  adoption,  and  by  vigorous  efforts  forced  it  upon  the  attention  of 
all  interested  in  gynecology  as  a  diagnostic  means  of  inestimable  value. 
Before  this  time  the  sound  was  practically  unknown  ;  after  it,  it  held  its 
place  as  one  of  our  most  valuable  diagnostic  resources. 

The  labors  of  Kecamier  marked  an  era  in  gynecology.  One  scarcely 
less  important  was  effected  by  those  of  Simpson,  who,  appearing  in  the 
field  about  the  year  1843,  created  an  enthusiasm  for  the  department,  and 
gave  an  impulse  to  it  by  the  vigor  and  originality  of  his  writings,  and  the 
brilliancy  of  his  contributions.  His  articles,  indeed,  first  incited  the  study 
of  uterine  displacements  in  Great  Britain,  and  to  his  efforts  may  be  traced, 
in  great  degree,  the  interest  which  has  been  of  late  years  aroused  in  that 
country  with  reference  to  uterine  pathology.  Until  this  time  the  subject 
had  attracted  very  little  attention  there,  and  advances  which  had  been  made 
in  it  were  due  almost  entirely  to  French  pathologists.  It  is  true  that  the 
excellent  work  of  Sir  Charles  Clarke  existed ;  but  that  warm  and  zealous 
interest  which  has  since  resulted  in  so  much  benefit  to  gynecology  had 
not  then  been  excited.  But  Prof.  Simpson  was  not  alone  in  this  work. 
Dr.  J.  H.  Bennet,  of  London,  at  that  time  a  young  physician,  who  had 
for  some  years  served  as  interne  in  the  hospitals  of  Paris,  returned  to  his 


28  HISTORICAL    SKETCH 

own  country  imbued  with  the  views  which  Recamier  and  Lisfranc  had 
disseminated  among  a  large  circle  of  followers.  In  1845,  the  first  edition 
of  his  work  on  Inflammation  of  the  Uterus  appeared,  and  it  is  safe  to  as- 
sert that  no  work  of  modern  times,  written  upon  any  subject  connected 
with  our  profession,  has  exerted  a  more  decided  and  profound  influence. 
Taking  up  the  matter  with  a  vigor  and  energy  which  forced  attention,  if 
not  conviction,  he  produced  an  undeniable  impression  upon  the  profession, 
not  only  in  his  own  country,  but  in  Germany,  France,  and  America.  The 
chief  points  insisted  upon  in  his  work  are  these :  1.  That  inflammation  is 
the  chief  factor  in  uterine  affections,  and  that  from  it  follow,  as  results, 
displacements,  ulcerations,  and  affections  of  the  appendages.  2.  That 
menstrual  troubles  and  leucorrhoea  are  merely  symptoms  of  this  morbid 
state.  3.  That  in  the  vast  majority  of  cases,  inflammatory  action  will  be 
found  to  confine  itself  to  the  cervical  canal,  and  not  to  affect  the  cavity  of 
the  body.  4.  The  propriety  of  attacking  the  disease  in  its  habitat  by  strong 
caustics. 

It  is  now  over  a  quarter  of  a  century  since  the  appearance  of  the  first 
edition  of  Dr.  Bennet's  work,  and  since  during  that  period  his  views  have 
been  freely  canvassed  and  vehemently  opposed,  since  too  his  own  experi- 
ence has  ripened  and  he  has  had  abundant  time  for  more  mature  reflec- 
tion, it  must  be  a  matter  of  great  interest  to  know  to  what  extent  his 
opinions  have  been  modified.  In  the  London  Lancet  appears  the  abstract 
of  a  paper  read  by  him  before  the  British  Medical  Association  in  1870, 
which  serves  to  contrast  his  more  recent  with  his  former  views. 

The  purport  of  this  paper  will  be  best  given  in  the  recapitulation  by 
which  the  author  concludes  it : — 

"  1.  I  consider  that,  under  the  influence  of  mechanical  doctrines  pushed 
to  an  extreme,  uterine  displacements  are  by  many  too  much  studied  per  se, 
independently  of  the  inflammatory  lesions  that  complicate  and  often  occa- 
sion them.  2.  That  the  examinations  made  to  ascertain  the  existence  of 
inflammatory  complications  are  often  not  made  with  sufficient  care  and 
minuteness,  as  evidenced  by  the  fact  that  I  constantly  see  in  practice  cases 
in  which  inflammatory  lesions  have  been  entirely  neglected,  and  the  second- 
ary displacements  alone  treated.  3.  That  inflammatory  lesions  are  often 
the  principal  cause  of  the  uterine  displacements  through  the  enlargement 
and  increased  weight  of  the  uterus,  or  of  a  portion  of  its  tissues,  which 
they  occasion.  4.  That  when  such  inflammatory  conditions  exist,  as  a  rule 
they  should  be  treated  and  cured,  and  then  time  given  to  nature  to  absorb 
morbid  enlargements  before  mechanical  means  of  treatment  are  resorted  to." 

Soon  after  the  appearance  of  Dr.  Bennet's  work,  a  discussion  sprang  up 
between  its  author  on  one  side,  and  Drs.  Robert  Lee,  West,  and  Tyler 
Smith  on  the  other,  with  reference  to  the  true  character  of  ulceration  of 
the  neck  ;  Dr.  Bennet  supporting  the  view  that  the  cervix  is  often  affected 
by  inflammatory  ulceration,  and  his  opponents  denying  it.     The  import- 


OF    GYNECOLOGY.  29 

ance  which  he  attached  to  the  matter  may  he  appreciated  from  the  follow- 
ing quotation.  In  reviewing  the  state  of  uterine  pathology  in  Great 
Britain,  as  illustrated  hy  the  standard  work  of  Sir  Charles  Clarke,  he 
says  :  "  Various  forms  of  cancerous  ulceration  are  carefully  described,  but 
the  very  existence  of  inflammatory  ulceration  is  not  mentioned.  Now, 
when  we  reflect  that,  as  I  shall  hereafter  show,  in  nearly  five  cases  out  of 
six  of  confirmed  uterine  disease,  in  which  chronic  discharges,  mucous, 
puriform,  or  sanguinolent,  or  other  well-marked  uterine  symptoms  are 
present,  there  exists  inflammation  or  inflammatory  ulceration  of  the  cer- 
vix, it  is  easy  to  conceive  how  erroneous  must  be  the  views  respecting 
uterine  pathology,  of  a  medical  school  ignorant  of  so  vitally  important  a 
circumstance." 

The  last  edition  of  Dr.  Bennet's  work  was  published  in  1861,  and  a 
quotation  of  the  views  held  by  him  in  1870  shows  that  they  were  essen- 
tially unaltered.  Yet  I  believe  that  I  am  correct  in  saying  that  the  great 
majority  of  the  progressive  gynecologists  of  our  time  sustain  the  views 
which  are  opposed  to  his.  I  find  myself  to-day  endorsing  the  action  of 
Sir  Charles  Clarke  in  publishing  a  work  on  diseases  of  women  "  in  which 
the  very  existence  of  inflammatory  ulceration  is  not  mentioned,"  or  is 
mentioned  only  for  the  purpose  of  disputing  its  validity. 

One  great  advance  which  was  effected  by  the  work  of  Dr.  Bennet  was 
the  placing  upon  a  surer  basis  than  it  had  yet  occupied,  the  differentiation 
of  engorgement  and  induration  from  commencing  cancer  of  the  neck. 

It  would  be  well,  before  proceeding  further,  to  consider  very  briefly  the 
different  pathological  views  which  from  this  time,  and  even  somewhat 
before  it,  were  offered  to  the  profession,  and  more  or  less  generally  adopted. 

They  may  be  thus  enumerated  : — 

1st.  That  inflammation  is  the  starting-point  of  most  of  the  affections 
of  the  uterus,  and  that  a  large  number  of  evils  follow  this  morbid  state  as 
results. 

2d.  That  uterine  disorder  is  dependent  upon  a  constitutional  derange- 
ment, and  would  yield  without  other  treatment  than  that  directed  to  the 
removal  of  the  general  condition. 

3d.  The  view  of  Dr.  Bennet,  which  is  similar  to  the  first  mentioned, 
with  this  additional  point,  that  metritis  generally  limits  itself  to  the  neck, 
and  only  exceptionally  affects  the  body. 

4th.  The  view  of  Dr.  Tyler  Smith,  that  leucorrhoea  arising  from  glandu- 
lar inflammation  in  the  cervix  is  the  cause  of  granular  derangement  of 
this  part,  and  of  subsequent  engorgement. 

oth.  The  view  that  uterine  disorders  often,  if  not  generally,  commence 
in  displacement,  which  is  a  primary  and  not  a  secondary  condition,  and 
that  to  relieve  the  train  of  morbid  symptoms,  this,  its  exciting  cause,  should 
be  first  removed. 

6th.  The  view  that  uterine  disorder  is  commonly  the  result  of  ovarian 


30  HISTORICAL    SKETCH 

inflammation,  which  reacting  on  the  womb  is  the  prime  mover,  in  many 
cases,  of  its  morbid  states. 

I  have  no  intention  of  fully  discussing  here  the  merits  of  these  theories, 
but  will  limit  myself  to  a  few  words  connected  with  each. 

The  theory  mentioned  first  in  this  enumeration  is  the  oldest  on  record, 
the  writers  of  the  Greek  School,  even,  adopting  it.  Tlius  Paulus  J£gi- 
neta  heads  his  chapter  on  the  subject,  "  Inflammation  of  the  uterus  and 
change  of  its  position."  One  of  the  symptoms  of  such  inflammation  he 
considers  to  be  retroversion  of  the  uterus.  In  the  beginning  of  the  pre- 
sent century  this  Mas  generally  accepted  in  France.  Lisfranc  and  R6- 
camier  adopted  it,  and  it  was  transferred  to,  and  advocated  in,  Great 
Britain  by  the  writings  of  Dr.  Bennet. 

The  views  of  this  last  author,  appearing  as  they  did  at  a  time  when  the 
field  of  uterine  pathology  was  almost  entirely  uncultivated,  and  character- 
ized as  they  were  by  a  great  deal  of  persuasive  force,  produced  in  this 
country  a  marked  impression.  As  to  myself  I  am  forced  freely  to  confess 
that  since  the  publication  of  the  first  edition  of  this  work  my  opinions  with 
regard  to  them  have  undergone  a  material  alteration.  This  alteration  has 
resulted  not  from  theoretical  reasoning,  but  from  careful  and  candid  inves- 
tigation and  experimentation  at  the  bedside.  I  have  come  to  regard  the 
belief  of  Dr.  Bennet  in  inflammation  as  the  great  moving  cause,  the  com- 
mon factor,  in  the  production  of  uterine  diseases,  as  an  error.  And  as 
my  views  have  thus  altered  with  reference  to  pathology,  they  have,  neces- 
sarily, likewise  changed  with  reference  to  treatment.  It  appears  to  me 
that  the  time  has  arrived  when  many  who  formerly  accepted  the  opinions 
of  Dr.  Bennet  will  be  prepared  to  admit  the  fact  that  his  treatment  is  too 
severe;  his  use  of  caustics  too  heroic;  and  his  neglect  of  artificial  support 
to  the  displaced  uterus  too  decided.  No  one  could  have  accepted  his  views 
more  cordially  than  I  did.  They  were  seductive  by  reason  of  their  sim- 
plicity, and  plausible  from  their  apparent  rationality.  Careful  observation 
at  the  bedside,  in  as  large  a  field  as  could  be  desired,  has  led  me  to  feel 
that  evil,  rather  than  good,  results  from  an  adherence  to  them.  Feeling 
this,  I  shall  strive  in  the  work  which  I  am  now  undertaking  so  to  modify 
my  statements  as  to  meet  what  I  regard  as  the  true  requirements  of  the 
subject. 

Let  us  however  bear  in  mind,  while  venturing  to  criticize  the  views  and 
practice  of  Dr.  Bennet,  that  science  is  progressive,  and  that  what  was  good 
a  quarter  of  a  century  ago  has  simply  given  place  to  what  is  better.  If, 
with  all  the  lights  of  modern  pathology,  we  stood  now  where  Dr.  Bennet 
stood  when  he  wrote,  the  discredit  would  have  been  with  us  ;  it  is  not 
with  him  that  we  do  not  do  so.  However  others  may  differ  from  him,  no 
candid  mind  can  deny  the  obligation  under  which  he  has  placed  his 
brethren  by  arousing  their  attention  and  directing  their  investigations  into 
proper  channels. 


OF    GYNECOLOGY.  31 

No  one  can  devote  himself  to  the  practical  study  of  uterine  diseases 
without  .being  impressed  with  the  strong  grounds  which  exist  for  the  main- 
tenance of  the  second  of  the  theories  mentioned.  No  grave  uterine  trouble  ■ 
affects  the  system  for  any  length  of  time  without  reacting  to  a  greater  or 
less  extent  upon  the  general  health.  The  nervous  system  becomes  greatly 
disordered,  the  functions  under  its  influence  are  badly  performed,  and  de- 
rangement in  hematosis  is  the  invariable  result.  As  the  local  disease 
often  approaches  stealthily,  and  may  exist  for  a  length  of  time  without 
exciting  suspicion,  what  is  more  natural  than  that  many  should  view  it 
as  one  of  the  numerous  results  of  the  general  depreciation  ?  These  three 
facts,  however,  which  will  constantly  repeat  themselves,  as  often,  I  may 
say,  as  favorable  cases  offer  for  testing  the  question,  will,  I  think,  very 
generally  lead  to  a  distrust  of  the  doctrine  :  1st,  the  fact  that  uterine 
disease  and  constitutional  derangement  existing  together,  a  cure  can 
rarely  be  effected  by  general  means  alone;  2d,  that  the  uterine  affec- 
tion being  removed,  the  general  state  is  at  once  improved  ;  and  3d,  that 
those  general  conditions  which  prostrate  the  vital  forces  to  the  last  degree, 
as,  for  instance,  tuberculosis,  uraemia,  scurvy,  leucocythaimia,  etc.,  destroy 
life  without  ever  showing,  unless  as  an  exception  to  a  rule,  uterine  disease 
as  a  consequence. 

The  constitutional  depreciation  of  a  woman  will,  however,  sometimes 
prove  a  predisposing  cause  of  local  disease.  As  granular  degeneration 
under  the  eyelids  will  arise  from  this  cause,  so  will  a  kindred  condition 
often  occur  on  the  cervix  uteri,  yet  both  will  require  local  as  well  as  gene- 
ral treatment.  The  enfeebled  woman  is  more  liable  to  subinvolution, 
passive  congestion,  and  displacements,  after  delivery,  than  the  strong ;  and 
inflammation  of  the  glands  of  the  cervix  is  a  well-known  result  of  phthisis 
pulmonalis,  tertiary  syphilis,  and  anajmia. 

The  theory  of  Dr.  Tyler  Smith1  I  lay  before  the  reader  in  his  own 
words:  "It  is  my  conviction,  notwithstanding,  that  in  the  majority  of 
cases  in  which  morbid  states  of  the  os  and  cervix  are  present,  cervical 
leucorrhoea,  or,  in  other  words,  a  morbidly  augmented  secretion  from  the 
mucous  glands  of  the  cervical  canal,  is  the  most  essential  part  of  the  dis- 
order, and  that  the  diseased  conditions  of  the  lower  segment  of  the  uterus, 
which  have  been  made  so  prominent,  are  often  secondary  affections  result- 
ing from  the  leucorrhoeal  malady."  This  theory  was  by  no  means  a  new 
one  when  advanced  as  above  mentioned,  for  Lisfranc2  mentions  it  thus: 
"  Observation  proves  that  leucorrhoea  can  in  the  first  place  cause  uterine 
engorgements,  and  that  later  it  may  be  kept  up  by  them ;  it  occasions 
them  often." 

Lisfranc,  however,  says  "  often,"  while  Dr.  Smith  says,  "  in  the  ma- 
jority of  cases."     But  even  before  Lisfranc  it  had  attracted  attention,  for 

1  On  Leucorrhoea.  2  Clin.  Chirurg.,  vol.  ii.  p.  303. 


32  HISTORICAL    SKETCH 

Paulus  jEgineta1  gives  "  defluxion"  as  one  of  the  causes  of  "  ulceration  of 
the  womb."  Tliat  an  acrid  leucorrhoeal  discharge  will  create  abrasion  of 
the  os,  follicular  vaginitis,  urethritis,  pudendal  inflammation,  and  pruritus, 
no  one  will  deny.  We  see  a  similar  irritation  occurring  on  the  upper  lip 
in  nasal  catarrh  in  children,  which  sometimes  spreads  as  an  eruption  over 
the  whole  face.  The  leucorrhoea  regarded  by  Dr.  Smith  as  the  primary 
disease  is,  however,  only  a  symptom  of  cervical  endometritis,  which  may 
disorder  nutrition  in  the  deep  tissues  of  the  cervix,  and  result  in  enlarge- 
ment and  induration.  The  views  of  Dr.  Smith  were  brought  forth  at  a 
time  when  Dr.  Bennet  was  pressing  the  theory  of  inflammation  as  the  key- 
stone of  uterine  pathology,  and  in  combating  the  idea  of  parenchymatous 
inflammation,  he  recorded  the  important  fact  that  the  morbid  state  de- 
scribed under  that  name  is  very  often  preceded  by,  and  results  from  disease 
taking  its  rise  in  the  mucous  lining  of  the  canal.  Dr.  Smith's  position 
was  maintained  with  all  that  ability  and  force  which  have  rendered  him 
so  popular  as  an  author  amongst  us  in  America,  and  the  influence  of  his 
writings  upon  uterine  pathology  can  be,  at  present,  clearly  traced  in  this 
country. 

In  the  year  1854,  a  discussion,  which  soon  assumed  extensive  propor- 
tions and  elicited  great  warmth,  arose  in  the  Academy  of  Medicine  of 
Paris,  with  reference  to  the  treatment  of  uterine  displacements.  M.  Vel- 
peau  stood  forth  as  champion  of  the  view  which  is  here  expressed  in  his 
own  words.  "  I  declare,  nevertheless,  that  the  majority  of  the  women 
treated  for  other  affections  of  the  uterus  have  only  displacements,  and  I 
affirm  that,  eighteen  times  out  of  twenty,  patients  suffering  from  disease  of 
the  womb,  or  of  some  other  part  of  this  region,  those  for  instance  in  whom 
they  diagnose  inflammation  (engorgements),  are  affected  by  displace- 
ments." In  this  and  subsequent  discussions  he  was  upheld  by  some  of  the 
most  eminent  practitioners  of  Paris,  and  by  many  the  view  then  expressed 
is  still  adhered  to.  No  one  of  experience  will  question  the  fact  that  a  dis- 
order of  position  of  the  uterus  will  often  result  in  subsequent  disorder  in 
nutrition  and  sensibility.  Every  one  must  have  repeatedly  met  with 
cases  in  which  the  reposition  and  support  of  a  displaced  uterus  have  at 
once  dissipated  a  collection  of  symptoms  which  by  many  would  have  been 
attributed  to  inflammation  of  the  mucous  lining  or  parenchyma.  Every 
one  must  have  found  in  many  cases  the  relief  of  a  displacement,  which  was 
regarded  as  only  an  unimportant  concomitant  of  the  morbid  state,  result 
in  complete  cure.  But  admitting  this  is  merely  admitting  the  propriety  of 
regarding  displacement  as  one  of  many  untoward  influences  which  may  dis- 
order the  innervation,  circulation,  and  nutrition  of  the  uterus  ;  not  making 
it  the  chief  factor  in  the  production  of  uterine  diseases. 

The  primary  importance  of  displacement  was  long  ably  maintained  in 

1  Op.  cit.,  p.  (324. 


OF    GYNECOLOGY.  33 

this  country  by  the  late  Prof.  Hugh  L.   Hodge,  of  Philadelphia,  :md  the 

adherents  of  this  theory  are  numerous. 

Tlie  most  signal  instance  of  its  adoption  which  has  recently  occurred  is 
that  of  Dr.  Graily  Hewitt,  of  London.  While  he  does  not  make  displace- 
ment absolutely  essential  as  a  primary  factor  of  uterine  disease,  and  limits 
his  belief  in  its  agency  almost  entirely  to  flexions  or  deformities  of  shape, 
the  importance  which  he  attaches  to  such  displacements  may  be  gathered 
from  the  following  quotations  from  the  third  edition  of  his  valuable  work 
upon  the  diseases  of  women. 

"  a.  Patients  suffering  from  symptoms  of  uterine  inflammation  (or,  more 
properly,  from  symptoms  referable  to  the  uterus)  are  almost  universally 
found  to  be  affected  with  flexion  or  alterations  in  the  shape  of  the  uterus 
of  easily  recognized  character,  but  varying  in  degree. 

"  b.  The  change  in  the  form  and  shape  of  the  uterus  is  frequently 
brought  about  in  consequence  of  the  tissues  of  the  uterus  being  previously 
in  a  state  of  unusual  softness,  or  what  may  be  often  correctly  designated 
as  chronic  inflammation. 

"c.  The  flexion  once  produced  is  not  only  liable  to  perpetuate  itself,  so 
to  speak,  but  continues  to  act  incessantly  as  the  cause  of  the  chronic  in- 
flammation present." 

In  a  certain  number  of  cases  very  grave  and  annoying  symptoms  of 
uterine  disease  will  be  found  due  to  chronic  ovaritis,  an  affection  in  which 
treatment  is  so  inefficient  that  every  practitioner  must  dread  to  meet  it. 
The  symptoms  of  uterine  disease  being  present,  an  exploration  of  the 
pelvic  organs  is  made.  No  uterine  disease  of  any  kind  is  found  to  exist, 
but  prolapsed  into  Douglas's  cul-de-sac  are  found  the  ovaries,  large,  tender, 
and  tumefied.  In  other  cases  uterine  disease  will  be  found  coexistent  with 
enlargement,  tenderness,  and  displacement  of  ovaries,  and  the  practitioner 
indulges  the  hope  that  so  soon  as  the  uterine  disorder  shall  be  cured  the 
ovarian  trouble  will  disappear.  Such  a  sequence,  however,  does  not  occur, 
and  he  recognizes,  to  his  disappointment,  that  what  he  regarded  as  a 
secondary  matter  is  really  one  of  primary  importance.  For  this  reason 
no  examination  of  the  pelvic  viscera  should  be  considered  complete  which 
does  not  involve  a  careful  investigation  of  the  state  of  the  ovaries. 

For  many  years  a  thorough  sceptic  as  to  the  frequency  of  ovarian  dis- 
order as  a  cause  of  the  ordinary  symptoms  of  uterine  disease,  I  am  now 
convinced  of  its  truth,  and  in  few  cases  do  I  give  more  guarded  prognoses 
than  in  those  in  which  I  find  one  or  both  ovaries  enlarged,  tender,  and 
prolapsed. 

Since  the  year  1850,  when  he  published  his  well-known  work  upon  the 
subject  of  Ovarian  Inflammation,  no  one  has  been  a  more  constant  or  con- 
sistent advocate  of  the  claims  of  ovarian  pathology  upon  the  notice  of 
the  gynecologist  than  Dr.  Tilt,  of  London.  At  a  meeting  of  the  London 
Obstetrical  Society,  in  April,  1873,  he  recapitulated  his  views,  and  it 
3 


34  HISTORICAL    SKETCH 

cannot  fail  to  be  a  matter  of  interest  to  see  how  time  and  experience  have 
affected  them.  The  positions  which  he  originally  took  were  these:  1st. 
That  the  recognized  frequency  of  inflammatory  lesions  in  the  ovaries  and 
in  the  tissues  that  surround  them  is  of  much  greater  practical  importance 
than  is  generally  admitted.  2d.  That  of  all  inflammatory  lesions  of  the 
ovary  those  involving  destruction  to  the  whole  organ  are  very  rare,  whilst 
the  most  numerous,  and,  therefore,  the  most  important,  may  be  ascribed 
to  a  disease  that  may  be  called  either  chronic  or  subacute  ovaritis.  3d. 
That,  as  a  rule,  pelvic  diseases  of  women  radiate  from  morbid  ovulation. 
4th.  That  morbid  ovulation  is  a  most  frequent  cause  of  ovaritis.  5th. 
That  ovaritis  frequently  causes  pelvic  peritonitis.  6th.  That  blood  is 
frequently  poured  out  from  the  ovary  and  the  oviducts  into  the  peritoneum. 
7th.  That  subacute  ovaritis  not  unfrequently  causes  and  prolongs  metritis. 
8th.  That  ovaritis  generally  leads  to  considerable  and  varied  disturbance 
of  menstruation.  9th.  That  some  chronic  ovarian  tumors  may  be  consid- 
ered as  aberrations  from  the  normal  structure  of  the  Graafian  cells. 

Dr.  Tilt  pointed  out  that  although  these  views,  when  promulgated,  had 
been  adversely  criticized  by  Drs.  Rigby,  West,  Bennet,  and  Churchill, 
they  were  now  to  a  great  extent  accepted,  and  that  they  have  been  amply 
demonstrated  both  clinically  and  microscopically  by  Aran,  Bernutz,  Gal- 
lard,  Negrier,  and  Siredey.  I  would  emphatically  dissent  from  his  3d 
postulate,  which  I  regard  as  entirely  too  sweeping  an  assertion,  but  with 
the  remaining  eight  I  fully  agree. 

Of  late  years  rapid  advances  have  been  made  in  the  surgical  treatment 
of  the  diseases  of  women.  Under  the  lead  of  Simpson,  Wells,  Brown, 
and  Keith,  in  Great  Britain;  of  Simon,  Esmarch,  Ulrich,  Hegar,  Spiegel- 
berg,  and  Schroeder,  in  Germany;  and  of  Sims,  Atlee,  Emmet,  Peaslee, 
Dunlap,  Agnew,  and  Kimball,  in  the  United  States ;  operations  for 
ovariotomy,  the  cure  of  ruptured  perineum,  vesico-vaginal  fistulae,  con- 
striction, or  tortuosity  of  the  cervix,  prolapsus  uteri,  laceration  of  the  cer- 
vix, etc.,  have  been  perfected  and  are  now  constantly  practised. 

During  the  last  quarter  of  a  century  three  men  have  led  the  profession 
in  the  surgical  portion  of  this  department,  and  by  their  originality  done  a 
great  deal  to  create  what  exists  to-day ;  Sims  in  America,  Baker  Brown 
in  England,  and  Simon  in  Germany.  Before  their  period  anaesthesia  was 
unknown  and  their  predecessors  lacked  its  aid.  For  them  it  offered  its 
rare  advantages,  and  they  hail  the  genius  to  make  good  use  of  them. 

Both  the  science  and  art  of  gynecology  have  been  greatly  advanced  by 
the  pathological  researches  of  the  German  school.  To-day  confessedly  in 
advance  of  all  other  nations  in  the  study  of  pathology,  the  laborious,  con- 
scientious, and  persevering  scholars  of  that  country  are  altering  and  im- 
proving our  views  in  reference  to  this  subject,  while  contributions  of  great 
practical  value  are  coming  forth  from  them  to  enrich  our  literature. 
Among   these  may  be  especially  mentioned  those  by  Kiwisch,  Hennig, 


OF    GYNECOLOGY.  35 

Waldeyer,  Simon,  Spiegelberg,  Martin,  Scanzoni,  Klob,  Schroeder,  Veit, 

and  Schultze. 

It  is  a  great  source  of  pleasure  to  me  before  closing  this  sketch  to  be 
able  to  record  the  fact  that  America  has  not  been  wanting  in  her  contribu- 
tion towards  the  progress  of  this  branch  of  medicine.  While  the  interests 
of  gynecology  were,  during  the  early  part  of  the  present  century,  advanced 
in  other  lands  by  those  whose  names  have  been  mentioned,  in  America 
they  were  pressed  upon  the  attention  of  the  profession  and  assiduously 
cultivated  by  three  able  advocates,  all,  singular  to  relate,  from  the  same 
city, — Dewees,  Meigs,  and  Hodge.  Each  of  these  observers  brought  to 
his  work  the  most  signal  ability  and  enthusiasm,  and,  having  abundant 
opportunities,  as  public  teachers  and  writers,  of  disseminating  their  views, 
they  each  exerted  a  decided  influence  upon  the  mind  of  the  profession. 
To  the  last  of  these  gentlemen  the  profession  throughout  the  world  is 
more  deeply  indebted  for  means  of  properly  sustaining  the  uterus  by  pes- 
saries than  to  any  one  else  who  has  ever  labored  in  this  field,  and  we  see 
in  our  day  his  determined  opposition  to  the  phlogistic  theory  of  uterine 
disorders  rapidly  gaining  advocates  amongst  the  ablest  and  most  philo- 
sophical in  our  ranks. 

From  this  country  have  emanated,  as  contributions  to  this  important 
department  of  medicine,  anaesthesia,  ovariotomy,  the  revival  of  the  method 
by  which  vaginal  fistulas  have  been  made  amenable  to  systematic  treat- 
ment, and  which  since  the  time  of  Gossett  had  been  entirely  forgotten ; 
and  last,  but  by  no  means  least,  the  introduction  into  ordinary  practice  of 
Sims's  methods  of  exploring  the  pelvic  viscera. 

I  have  elsewhere  called  the  results  of  the  labors  of  Recamier  and  Simp- 
son eras  in  the  progress  of  this  department.  I  now  venture  so  to  style 
those  of  Marion  Sims.  In  doing  this  I  make  no  reference  to  the  improve- 
ments inaugurated  by  him  in  the  treatment  of  injuries  to  the  genital 
organs;  my  allusion  is  to  the  great  advantages  which  now  flow  and  are  to 
flow  from  the  invention  of  his  speculum,  which  exposes  the  uterus  by  a 
new  principle,  and  opens  the  way  to  a  more  complete  examination  of  that 
organ.  Recamier  marked  an  era  by  improving  our  powers  of  diagnosis  in 
exposing  the  cervix  uteri ;  Simpson  another,  by  opening  to  investigation 
the  body  of  the  uterus;  and  Sims  a  third,  by  rendering  both  investigations 
more  simple,  complete,  and  satisfactory. 

There  is  no  more  certain  way  of  appreciating  the  effect  of  light  than  by 
withdrawing  it  and  marking  the  degree  of  darkness  which  results.  If  all 
that  Sims  has  done  for  gynecology  were  suppressed,  we  should  find  that 
we  had  retrograded  at  least  a  quarter  of  a  century. 

The  ordinary  specula  in  use  before  the  discovery  of  Sims's,  simply  sepa- 
rate the  vaginal  walls  mechanically,  and  thus  expose  the  uterus.  Sims's 
instrument,  on  the  other  hand,  elevates  the  posterior  vaginal  wall,  which 
allows  the  entrance  of  air  to  distend  the  whole  passage,  the  woman  lying 


36  HISTORICAL    SKETCH 

on  her  side  in  such  a  manner  that  the  cavity  can  be  probed  with  the  most 
perfect  ease,  and  applications  made  to  the  fundus.  I  am  fully  aware  that 
many  will  differ  from  me  in  this  opinion,  but  being  entirely  free  from  preju- 
dice in  favor  of  this  instrument,  or  against  the  ordinary  varieties,  I  main- 
tain it  fearlessly,  feeling  confident  that  time  will  prove  it  to  be  correct. 
No  one  who  has  not  tested  the  two  methods  of  examination  is  really  enti- 
tled to  an  opinion  upon  the  point,  and  I  cannot  doubt  the  conclusion  of 
him  who  has  done  so  faithfully  and  intelligently. 

It  may  very  pertinently  be  asked  how  I  reconcile  this  opinion  with  the 
facts  that  with  the  exception  of  Emmet  in  his  recent  work,  and  myself, 
no  other  writer  of  a  systematic  treatise  on  gynecology  recommends  this 
method  of  exploration  in  preference  to  that  by  the  cylindrical  speculum  in 
daily  practice ;  that  few,  if  any,  of  the  gynecologists  of  Great  Britain  or 
the  continent  of  Europe  employ  it  to  the  exclusion  of  the  old  plan  in  ordi- 
nary cases;  and  that  even  in  this  city,  where  the  personal  advocacy  of 
Sims  himself  and  the  wide-spread  influence  of  the  Woman's  Hospital 
which  he  has  founded  are  felt,  only  a  score  of  practitioners  do  so,  most  of 
whom  are  connected  with  this  hospital.  My  explanation  of  the  facts  is 
this  :  to  employ  Sims's  speculum  efficiently  considerable  experience  with 
it  is  necessary.  One  who  has  not  practised  with  it  so  as  to  become  skilful 
will  find  it  far  less  useful  than  the  cylindrical  and  valvular  specula  in  ordi- 
nary use.  I  feel  sure  that  most  of  those  who  have  tried  it  and  cast  it  aside, 
except  for  operations  on  the  vagina  or  uterus,  have  attributed  their  own 
shortcomings  to  an  instrument  the  use  of  which  they  had  not  mastered. 
Again,  it  is  necessary  to  have  an  assistant,  and  highly  desirable  to  have  a 
practised  assistant,  to  hold  the  speculum.  None  of  the  substitutes  for 
such  an  assistant  have  ever  proved  or,  I  think,  will  ever  prove  effectual. 
For  this  reason  also  the  use  of  this  instrument  has  not  become  more 
general. 

It  is  becoming  customary,  with  those  who  practise  gynecology  as  special- 
ists in  this  city  and  employ  this  speculum,  to  see  their  patients  almost 
universally  at  their  offices,  and  to  have  in  attendance  a  trained  nurse  who 
manages  both  patient  and  instrument  during  examinations.  One  prac- 
tising in  this  manner  places  himself,  I  am  confident,  on  a  vantage  ground, 
which  can  scarcely  be  imagined  by  him  who  clings  to  the  old  methods  of 
exploration.  The  experience  required,  however,  to  use  this  speculum  with 
advantage,  and  the  disadvantage  of  its  requiring  the  aid  of  a  nurse,  will 
prevent  its  universal  or  even  very  general  adoption.  I  do  not  believe  that 
the  practitioner  who  sees  very  little  of  uterine  disease  will  ever  employ  it. 
But  there  are  at  present  many  who  are  studying  and  practising  gynecology 
extensively  and  scientifically.  It  is  to  such  that  these  remarks  are  espe- 
cially addressed. 

In  stating  all  this  thus  plainly  and  positively,  I  am  by  no  means  igno- 
rant of  the  criticism  to  which  I  expose  myself  from  an  overwhelming  and 


OF    GYNECOLOGY.  37 

most  influential  majority.  I  confess  that  even  to  me  the  slow  advance 
made  by  Sinis's  speculum,  as  an  instrument  for  every-day  use,  lias  been 
a  matter  of  great  surprise.  Familiarized,  however,  by  years  of  practice 
with  both  methods  of  examination,  and  prejudiced  in  favor  of  neither,  I 
cannot  doubt  the  result.  The  assertion  of  its  rights  by  the  new  method 
will  give  an  impetus  to  the  advance  of  gynecology  which  in  some  degree 
it  has  even  now  effected. 

I  cannot  close  tin's  part  of  my  subject  without  appealing  to  those  work- 
ing in  tins  department  who  are  willing  to  test  the  matter,  in  the  following 
manner.  Learn  the  use  of  Sims's  speculum,  not  by  personal  labor  and 
experiment,  but  from  one  who  is  fully  master  of  it ;  have  at  your  disposal 
a  trained  nurse,  and  persevere  with  the  method  for  three  months,  and  you 
will  endorse  the  statement  as  to  the  vantage  ground  which  you  will  occupy, 
which  just  now  appears  so  exaggerated  to  you.  Nothing  is  easier  than  to 
attack  upon  paper  such  a  position  as  that  which  I  have  here  assumed ; 
nothing  more  tempting  than  a  half  humorous,  half  sarcastic  review  of  it. 
But  the  question  is  one  of  too  great  moment  to  be  thus  dealt  with.  All 
earnest  workers  in  our  ranks  are  in  search  after  truth,  not  striving  to  prove 
themselves  right ;  all  wise  men  are  eager  to  avail  themselves  of  improve- 
ments in  their  calling,  not  to  find  warrant  for  hugging  what  is  old. 

Although  the  scope  of  this  chapter  will  not  admit  of  the  mention  of  all 
the  works  which  have  recently  appeared  upon  this  subject,  I  cannot  refrain 
from  mentioning  one  which  comes  to  us  offering,  among  other  valuable 
contributions,  one  of  the  most  important  pathological  facts,  and  with  it  its 
corresponding  surgical  resource,  which  the  last  half  century  has  yielded. 
The  work  is  the  highly  original  and  valuable  one  of  Dr.  Thomas  Addis 
Emmet,  of  New  York  ;  the  pathological  contribution  which,  even  if  this 
eminent  author  had  done  nothing  else  to  lay  his  profession  under  obliga- 
tion, would  indelibly  write  his  name  upon  the  records  of  gynecology,  is 
the  diagnosis  and  treatment  of  laceration  of  the  cervix  uteri.  No  one 
contribution  to  this  department  which  has  been  made  in  the  period  men- 
tioned has  exerted  a  more  marked  influence  upon  uterine  pathology  than 
this  is  now  doing,  and  will  do  in  the  future.  None  will  have  more  influ- 
ence in  abolishing  useless  and  hurtful  therapeutical  resources. 

During  the  past  thirty  years  a  decided  effort  has  been  made  all  over 
the  civilized  world  to  introduce  into  medicine  a  remarkable  innovation — 
the  opening  of  its  doors  to  the  entrance  of  women  as  practitioners.  The 
prevalent  and  very  just  sentiment,  that  the  gentle  and  sympathetic  nature 
of  woman  would,  in  this  department  of  labor,  find  an  appropriate  field  of 
action,  at  that  period  began  to  be  clearly  expressed,  and  the  urgent  de- 
mand which  was  made  by  progressive  minds  in  different  countries  has  at 
the  present  day  been  fully  met.  This  has  not  been  accomplished  without 
opposition.  The  usual  adverse  striving  of  narrow  and  non-progressive 
minds  has  not  been  wanting  to  retard  the  advance  of  the  movement,  but 


38  HISTORICAL    SKETCH 

in  spite  of  this,  with  an  almost  unprecedented  rapidity  when  its  magnitude 
is  considered,  it  has  arrived  at  assured  success. 

The  connection  of  woman  with  the  practice  of  medicine  is  a  matter  of 
no  recent  date.  The  sentiment  which  fosters  it  now  has  existed  in  an  un- 
developed state  from  the  earliest  ages.  Aetius  makes  mention  of  the  writ- 
ings and  practice  of  Aspasia,  who  was  a  doctress  at  Rome  about  the  third 
century,  and  copies  extensively  from  her  upon  ulceration  and  displace- 
ments of  the  womb.  Paulus  -/Egineta  is,  for  some  of  his  chapters,  in- 
debted to  Cleopatra,  fragments  of  whose  writings  he  has  preserved  for  us. 
He  evidently  quotes  her  with  respect,  and  credits  her  with  what  he  bor- 
rows. In  the  thirteenth  century  an  Arabian  woman,  Trotula  by  name, 
published  a  treatise,  in  which  she  mentions  that  many  Saracenic  women 
practised  the  art  of  obstetrics  at  Salerno.  In  later  times,  during  the 
seventeenth  and  eighteenth  centuries,  women  were  graduated  as  Doctors 
of  Medicine  in  the  Italian  Universities,  and  as  such  enjoyed  great  con- 
sideration. In  1732,  La  Dottoressa  Laura  Bassi  graduated  at  Bologna, 
and  filled  the  chair  of  Natural  Philosophy  for  six  years.  In  the  last  part 
of  the  eighteenth  century,  Madonna  Mazzonlina  lectured  on  anatomy  at 
Bologna,  while  others  of  lesser  note  filled  positions  of  minor  importance. 
To  the  women  of  Arabian  civilization  the  department  of  obstetrics  was 
entirely  surrendered ;  for  so  great  were  the  sensuality  and  libertinism  of 
the  Saracens,  that  the  Mahommedan  laws  prohibited  the  attendance  of 
males  upon  females ;  and  thus  their  whole  treatment,  except  in  extreme 
cases,  devolved  upon  the  midwives. 

In  France  a  portion  of  the  work  of  medicine  has  long  been  allotted  to 
"  Sages  Femmes"  or  midwives,  and  the  names  of  Mmes.  La  Chapelle  and 
Boivin,  who  lived  in  the  last  part  of  the  eighteenth  and  the  beginning  of 
the  nineteenth  centuries,  come  to  us  clothed  with  great  authority. 

The  demand  of  our  time  then  is  not  that  woman  may  practise  medicine, 
but  that  she  should  have  every  opportunity  which  that  time  offers  her  to 
prepare  herself  for  the  work.  Many  have  doubted,  and  upon  excellent 
grounds,  the  ability  of  woman  to  cope  with  man  in  this  field  of  labor,  for 
there  is  no  resisting  the  evidences  of  history,  that,  in  spite  of  opportunities 
and  incentives,  female  practitioners  have  failed  in  time  past,  not  only  to 
advance,  but  even  to  maintain  the  integrity  of  the  art  intrusted  to  their 
hands.  The  experience  of  the  future  may  contradict  that  of  the  past ;  but 
even  its  doing  so  will  offer  no  good  reason  for  despising  the  lesson  which 
the  past  has  left  on  record.  As  futile  would  it  be,  however,  to  resist  the 
overwhelming  "  logic  of  events,"  and  to  shut  our  eyes  to  the  fact  that  the 
"  woman  movement"  has  conquered  for  itself  in  medicine  a  position  which 
entitles  it  to  consideration  and  respect. 

The  opportunity  which  is  now  offered  to  woman  for  retrieving  what  has 
been  lost  in  former  ages  is  certainly  all  that  the  most  exacting  of  modern 
reformers  could  require.     The  prejudice  which  for  years  existed  against 


OF    GYNECOLOGY.  39 

lier  in  this  connection  appears  to  be,  in  this  country  and  in  Europe,  almost 
entirely  eradicated.  In  many  of  the  most  ancient  and  eminent  of  the  uni- 
versities of  Europe  they  are  free  to  matriculate,  and  in  most  of  the  largest 
cities  both  of  Europe  and  America  female  medical  colleges  exist.  In  this 
city,  some  of  the  most  able  of  our  junior  teachers  are  engaged  in  instruc- 
tion in  the  Female  Medical  College,  and  many  of  the  most  eminent  and 
conservative  of  the  senior  members  of  the  medical  profession  have  accepted 
positions  as  consultants  to  the  hospital  attached  to  the  college.  Female 
practitioners  are  freely  met  in  consultation  in  general  practice,  and  the 
County  Medical  Society,  one  of  the  two  representative  associations  of  the 
city,  admits  them  to  its  ranks  as  members.  The  general  and  sincere  feel- 
ing of  the  progressive  and  most  prominent  members  of  the  medical  profes- 
sion here  is  unquestionably  this,  to  allow  to  females  a  fair  opportunity  to 
enter  the  field  of  medicine,  and  strive  to  establish  their  ability  to  perform 
its  arduous  functions,  however  much  they  may  doubt  the  success  of  the 
enterprise.  All  appear  willing  to  intrust  the  solution  of  the  problem  of 
woman's  fitness  for  the  duties  of  medicine  to  time,  the  great  crucible  of 
human  theories. 

"  The  burning  question,"  says  J.  R.  Chadwick,  in  an  excellent  review 
of  this  subject,  "is  no  longer,  shall  women  be  allowed  to  practise  medi- 
cine? They  are  practising  it;  not  by  ones  or  twos,  but  by  hundreds; 
and  the  only  problem  now  is,  shall  we  give  them  opportunities  for  study- 
ing medicine  before  they  avail  themselves  of  the  already  acquired  right  of 
practising  it?"  Admitting  that  this  question  is  justly  put,  can  any  one 
wishing  well  to  humanity  and  to  science  venture  to  array  himself  on  the 
negative  side? 

An  innovation  in  general  surgery  which  bids  fair  to  be  one  of  the 
greatest  improvements  which  has  ever  been  effected  in  that  art  has  been 
reserved  for  our  time — the  establishment  upon  a  systematic  basis  of  anti- 
septic surgery.  No  departments  of  surgery  will  feel,  indeed  are  now  feel- 
ing, the  iniluence  of  this  more  decidedly  than  those  of  gynecology  and 
obstetrics.  The  great  evil  from  which  they  have  suffered  is  septicaemia, 
and  this  it  is  the  special  object  of  Listerism  to  prevent  and  overcome. 
Not  only  does  this  method  offer  great  advantages  in  ovariotomy,  in  all  its 
details  except  the  use  of  the  spray  it  may  with  the  greatest  advantage  be 
applied  to  all  operations  within  the  pelvis. 

I  am  so  often  consulted  by  recent  graduates  as  to  the  works  which  they 
should  make  the  basis  of  a  library  upon  gynecology,  that  I  feel  that  I  may 
render  a  service  by  the  following  list.  Only  such  works  are  recorded  as 
will  prove  of  absolute  service  to  the  active  practitioner  who  seeks  know- 
ledge chiefly  upon  practical  points  : — 

Xonat— Maladies  de  l'Uterus,  1  vol. 
Aran — Maladies  de  l'Uterus,  1  vol. 
Becquerel — Maladies  de  TUterus,  2  vols. 


40  HISTORICAL    SKETCH    OF    GYNECOLOGY. 

Blatin  et  Nivet — Maladies  des  Femraes,  1  vol. 

West — Diseases  of  Women,  1  vol. 

Tilt— Uterine  and  Ovarian  Inflammation,  1  vol. 

Bennet— On  the  Uterus,  1  vol. 

Simpson — Diseases  of  Women,  1  vol. 

Hewitt — Diseases  of  Women,  1  vol. 

Churchill — Diseases  of  Women,  1  vol. 

Byford— Medical  and  Surgical  Treatment  of  Women,  1  vol. 

Sims— Uterine  Surgery,  1  vol. 

Baker  Brown — Surgical  Diseases  of  Women,  1  vol. 

Tilt — Uterine  Therapeutics,  1  vol. 

Scanzoni— Diseases  of  Females,  1  vol. 

Meigs — Diseases  Peculiar  to  Females,  1  vol. 

Bedford — Diseases  of  Women  and  Children,  1  vol. 

Colomhat — On  Females  (annotated  by  Meigs),  1  vol. 

Ashwell — Diseases  of  Women,  1  vol. 

McClintock — Diseases  of  Women,  1  vol. 

Courty— Maladies  de  1 'Uterus  et  de  ses  Annexes,  1  vol. 

Hodge — Diseases  Peculiar  to  Women,  1  vol. 

Klob — Pathological  Anatomy  of  the  Female  Genital  Organs,  1  vol. 

Spencer  Wells— On  Diseases  of  the  Ovaries. 

Kiwisch — On  Diseases  of  the  Ovaries,  1  vol. 

Wright — Diseases  of  Women,  1  vol. 

Emmet— On  Vesico- Vaginal  Fistulse,  1  vol. 

Duncan — Parametritis  and  Perimetritis,  1  vol. 

Duncan — Fecundity,  Fertility,  and  Sterility,  1  vol. 

Athill — Diseases  of  Women,  1  vol. 

Gallard—  Lecons  Clinique  sur  les  Maladies  des  Femmes,  1  vol. 

Peaslee— Ovarian  Tumors,  1  vol. 

Atlee— Ovarian  Tumors,  1  vol. 

Barnes — Treatise  on  Diseases  of  Women. 

Goodell — Clinical  Lectures  on  Diseases  of  Women,  1  vol. 

Leblond — Traite  Elementaire  de  Chirurgie  Gynecol ogique,  1  vol. 

Schroeder— Diseases  of  Female  Sexual  Organs,  1  vol. 

Tait— Diseases  of  Women,  1  vol. 

Emmet— Principles  and  Practice  of  Gynecology,  1  vol. 

Hegar  and  Kaltenbach— Die  Operative  Gyniikologie,  1  vol. 

Skene— Diseases  of  the  Bladder  and  Urethra  in  Women,  1  vol. 

Mary  Putnam  Jacobi — The  Question  of  Rest  for  Women. 

Martineau— Traite  Clin,  des  Aftec.  de  TUterus. 

The  following  journals  are  now  devoted  to  this  subject: — 

Centralblatt  fur  Gynecologic 

Annales  de  Gynecologic. 

Obstetrical  Journal  of  Great  Britain  and  Ireland. 

American  Journal  of  Obstetrics  and  Diseases  of  Women  and  Children. 

Obstetric  Gazette. 

Archiv  fur  Gyniikologie. 


ETIOLOGY    OF    DISEASES    PECULIAR    TO    WOMEN.  41 


CHAPTER  II. 

THE  ETIOLOGY  OF  THE  DISEASES  PECULIAR  TO  WOMEN. 

In  investigating  the  causes  of  the  diseases  peculiar  to  women  I  shall 
especially  refer  to  those  which  are  active  in  this  country.  In  doing  this 
I  desire  to  avoid  all  comparison  between  the  frequency  of  such  affections 
here  and  abroad,  for  in  the  absence  of  statistical  evidence  such  an  attempt 
would  necessarily  prove  futile.  My  chief  reason  for  giving  myself  the 
limits  herein  prescribed  is  my  desire  to  base  the  views  advanced  in  this 
chapter  entirely  upon  personal  observation,  to  offer  to  the  reader  not  the 
conventional  doctrines  prevalent  upon  the  subject  of  which  it  treats,  but 
those  views  which  have  impressed  themselves  upon  my  own  mind  as  valid 
and  valuable.  With  this  object  in  view,  it  is  manifestly  easier  to  write  of 
habits  and  influences  which  come  under  one's  daily  observation  and  con- 
nect themselves  with  the  experience  of  his  daily  life. 

I  shall  divide  the  causes  to  which  I  shall  draw  attention  into  predis- 
posing and  exciting,  premising  their  enumeration  by  the  announcement 
that  I  do  not  propose  to  mention  all  of  the  former  which  are  active,  but 
to  limit  myself  to  those  which  are  most  prominent,  and  which  are  to  a 
great  degree-  avoidable.  Others,  such,  for  example,  as  inherited  constitu- 
tional vices,  will  be  spoken  of  in  connection  with  special  diseases  as  they 
come  under  notice.  Considering  very  fully  the  predisposing  causes,  I  shall 
give  merely  an  enumeration  of  the  chief  exciting  ones,  leaving  the  fuller 
consideration  of  the  latter  also  for  chapters  devoted  to  special  affections. 

If  we  compare  the  present  state  of  women  in  refined  society  over  the 
world  with  that  of  the  working  peasants  of  the  same  latitudes,  or  with  the 
North  American  squaws,  or  the  powerful  negresses  of  the  Southern  States, 
we  can  with  difficulty  believe  that  they  all  sprung  from  the  same  parent 
stem,  and  originally  possessed  the  same  physical  capacities.  Observation 
proves  that  women  who  are  not  exposed  to  depreciating  influences  can 
compete  in  strength  and  endurance  with  the  men  of  their  races,  and  in 
savage  countries  they  are  sometimes  regarded  as  superior  to  them.  In  the 
lower  orders  of  animals  this  equality  is  still  more  marked.  The  mare 
endures  as  much  as  the  horse,  and  some  of  our  most  celebrated  racers  have 
represented  the  female  sex.  The  lioness  is  fully  as  dangerous  to  the  hun- 
ter as  her  more  majestic  consort,  and  the  bitch  proves  as  untiring  in  the 
chase  as  the  most  muscular  dog  in  the  pack 

From  all  these  facts  we  may  logically  argue,  that  the  human  female,  if 


42  ETIOLOGY    OF    THE    DISEASES 

properly  developed  and  placed  beyond  causes  which  militate  against  her 
physical  well-being,  would  be  ir  no  great  degree  the  inferior  of  the  male. 
This  position  I  now  assume,  and  maintain  that  the  customs  of  civilized 
life  have  depreciated  her  powers  of  endurance  and  capacity  for  resisting 
disease.  My  efforts  will  be  directed  to  an  endeavor  to  point  out  what 
these  habits  and  influences  are.  I  do  not,  of  course,  advance  the  state- 
ment that  uterine  diseases  are  unknown  among  uncivilized  women,  for  I 
have  too  often  seen  prolapsus,  retroversion,  granular  degeneration,  and 
kindred  disorders  among  the  former  slaves  of  this  country  to  do  so.  These 
affections  were,  however,  rare  among  them,  and  not  exceedingly  common, 
as  they  are  amongst  our  white  women,  and  even  when  they  existed,  they 
did  not  so  profoundly  affect  the  constitutions  of  those  suffering  from  them. 
As  I  shall  hereafter  point  out,  injuries  inflicted  by  parturition  play  a  most 
important  role  in  the  causation  of  these  disorders.  To  such  injuries  as 
laceration  of  the  perineum  and  cervix,  disorders  of  involution,  etc.,  the 
savage  woman  is  unquestionably  liable,  and  their  occurrence  would  entail 
upon  her  the  same  evils  which  would  result  from  them  in  the  civilized. 
Yet  how  much  less  liable  to  their  occurrence  is  the  strong,  well-developed, 
muscular  frame  of  the  former  than  the  delicate  sensitive  organization  of 
the  latter !  And  even  if  exposed  to  the  baneful  influence  of  these  acci- 
dents, how  much  more  able  is  she  to  resist  their  depreciating  influences ! 
There  are  in  this  city  to-day  thousands  of  poor  women  who  go  through 
with  the  labors  of  their  lives  of  drudgery  with  the  uterus,  vagina,  and  por- 
tions of  the  bladder  and  rectum  in  the  condition  of  complete  prolapse,  the 
first  two  organs  entirely,  and  the  last  two  in  great  degree,  outside  of  their 
bodies.  How  differently  would  the  refined  woman  of  a  higher  sphere  be 
affected  by  a  similar  condition,  and  how  utterly  wretched  would  her  life 
ordinarily  be  rendered ! 

In  a  woman  of  robust  frame,  healthy  nervous  system,  and  perfect  blood 
state,  who  lives  a  rational  and  carefully  regulated  life,  an  accident,  occur- 
ring at  parturition,  during  menstruation,  or  at  any  time  disconnected  with 
these  trying  periods,  may  produce  serious  disease.  But  in  such  a  woman 
accidents  are  much  less  likely  to  occur,  and  even  if  they  did  so  would  pro- 
duce much  less  serious  consequences  than  in  one  in  whom  the  predisposing 
causes  of  disease  of  the  genital  system  had  for  a  lifetime,  and  even  longer, 
for  hereditary  influences  are  powerful  for  evil  in  this  connection,  prepared 
the  way  for  the  easy  establishment  of  pathological  conditions. 

Those  influences  which,  growing  out  of  the  physically  depreciating 
habits  of  civilized  life,  tend  most  decidedly  to  develop  a  predisposition  to 
diseases  of  the  female  genitalia  may  thus  be  enumerated  : — 

Neglect  of  out-door  exercise  and  physical  development. 

Overwork  of  brain,  and  excessive  development  of  nervous  system. 

Improprieties  of  dress. 

Imprudence  during  menstruation. 


PECULIAR    TO    WOMEN.  43 

Imprudence  after  parturition. 

Non-recognition  or  neglect,  on  the  part  of  the  obstetrician,  of  injuries 
due  to  parturition. 

Prevention  of  conception  and  induction  of  abortion. 
Marriage  with  existing  disease  of  genitalia. 
Insufficient  food. 
Habitual  constipation. 

Neglect  of  Exercise  and  Physical  Development There  can   be   no 

doubt  of  the  fact  that,  as  a  general  rule,  in  the  higher  walks  of  life 
throughout  the  civilized  world,  the  female,  from  infancy  to  old  age,  takes 
much  less  exercise  than  the  male,  and  in  the  United  States,  owing  to  pe- 
culiarities of  climate,  this  disproportion  is  probably  more  marked  than 
in  the  countries  of  Europe.  It  is  true  that  the  last  decade  has  seen  a 
most  gratifying  improvement  in  this  respect,  and  that  the  practice  of  out- 
door amusements,  such  as  rowing,  bowling,  archery,  walking,  croquet, 
horseback  exercise,  etc.,  has  become  much  more  general. 

This,  however,  is  greatly  confined  to  the  inhabitants  of  cities  and  to 
very  young  women,  and  even  among  these  it  must  become  much  more 
general  than  it  is  to-day  for  it  to  produce  the  results  which  may  in  time  be 
expected  from  it.  The  female  by  nature  is  as  a  rule  much  more  inclined 
to  a  sedentary  life  than  the  male,  and  as  her  occupations  keep  her  indoors 
she  is  apt,  whether  living  in  city  or  country,  to  lose  all  taste  for  out-door 
amusements,  and  to  confine  herself  to  the  close,  heated  air  of  inhabited 
apartments.  Among  our  farming  population,  where  all  the  out-door  work 
is  done  by  the  males,  the  women  commonly  take  less  exercise  in  the  open 
air  than  do  those  in  our  cities,  and  much  of  their  time  is  spent  in  rooms 
heated  by  stoves  which  cook  the  air  and  render  it  dry  and  unwholesome. 

In  spite  of  the  improvement  we  have  mentioned,  in  our  cities  will,  to- 
day, be  found  hundreds  of  ladies  who  do  not  walk  a  mile  a  day  for  weeks 
together,  and  many  more  who  have  never  engaged  in  any  exercise  which 
called  forth  the  action  of  other  muscles  than  those  employed  in  the  quietest 
locomotion. 

But  nowhere  is  the  neglect  of  early  physical  development  more  marked 
than  in  our  boarding-schools  and  female  seminaries,  where  every  hour  of 
the  day  from  six  in  the  morning  to  nine  at  night  is  allotted  by  rule  to 
some  special  task.  Instead  of  the  girls  being  encouraged  to  engage  in  out- 
door pursuits  calculated  to  create  muscular  power,  they  are  reared  in  the 
belief  that  such  pastimes  are  hoydenish,  unbecoming,  and  fit  only  for 
rough  boys.  Their  hours  of  leisure  are  occupied  by  reading,  music,  draw- 
ing, or  some  similar  light  task,  and  an  hour's  walk  every  day  is  regarded 
as  a  degree  of  exercise  quite  sufficient  for  the  requirements  of  health.  By 
this  plan  the  mind  is  constantly  kept  in  the  thraldom  of  control,  and  chafes 
under  the  depressing  influence  of  a  never-ending  surveillance.     A  set  of 


44  ETIOLOGY  OF  THE  DISEASES 

romping  school-girls  could  as  profitably  laugh  by  rule  as  really  enjoy  and 
improve  by  exercise  under  the  eye  of  an  instructress  or  professor  of  calis- 
thenics. It  is  not  the  mere  bodily  exertion  which  is  of  benefit,  but  the 
total  mental  relaxation,  the  exhilaration  and  the  abandon  which  accom- 
pany it.  The  prisoner  working  for  eight  hours  on  the  treadmill  does  not 
profit  by  it  as  the  free  and  happy  equestrian  or  oarsman  does  by  one- 
eighth  the  time  of  exercise. 

One  of  the  most  important  results  of  exercise  is  the  increase  of  the 
peripheral  circulation.  This  increases  cutaneous  exhalation,  and  tends  to 
equalize  the  circulation.  The  woman  who  neglects  it  is  peculiarly  prone 
to  excessive  uterine  and  ovarian  congestion  at  menstrual  epochs,  and  to 
sluggish  circulation  in  these  parts  at  all  times.  It  is  this  fact  which 
explains  the  excellent  results  attainable  in  cases  of  uterine  and  ovarian 
disease  from  the  use  of  passive  motion  by  the  Swedish  movement  cure, 
the  Turkish  bath,  surf  bathing,  and  other  methods  which  create  tumes- 
cence of  the  cutaneous  capillaries,  and  exalt  metamorphosis  of  tissue  in  the 
periphery  of  the  body.  One  of  the  most  valuable  and  beneficent  means  of 
treating  these  diseases  that  I  know  of  is  the  use  night  and  morning  of  a 
warm  sponge-bath  of  water  strongly  impregnated  with  salt,  followed  by 
thorough  friction  with  a  rough  towel  and  calisthenic  exercises  for  five  or 
ten  minutes. 

Excessive  Development  of  the  Nervous  System — The  necessity  for  a  due 
proportion  existing  between  the  development  and  strength  of  the  nervous 
and  muscular  systems  has  always  been  recognized,  and  has  given  rise  to 
the  trite  formula,  "mens  sana  in  corpore  sano,"  as  essential  to  health. 
Unfortunately  the  restless,  energetic,  and  ambitious  spirit  which  actuates 
the  people  of  the  United  States,  has  prompted  a  plan  of  education  which 
by  its  severity  creates  a  vast  disproportion  between  these  two  systems, 
and  its  effects  are  more  especially  exerted  upon  the  female  sex,  in  which 
the  tendency  to  such  loss  of  balance  is  much  more  marked  than  in  the 
male.  Girls  of  tender  age  are  required  to  apply  their  minds  too  constantly, 
to  master  studies  which  are  too  difficult,  and  to  tax  their  intellects  by 
efforts  of  thought  and  memory  which  are  too  prolonged  and  laborious.  The 
results  are,  rapid  development  of  brain  and  nervous  system,  precocious 
talent,  refined  and  cultivated  taste,  and  a  fascinating  vivacity  on  the  one 
hand  ;  a  morbid  impressibility,  great  feebleness  of  muscular  system,  and 
marked  tendency  to  disease  in  the  generative  organs,  on  the  other. 

That  this  statement  of  the  advantages  which  are  gained  and  the  price 
which  is  paid  for  them  is  perfectly  true,  no  American  practitioner  will 
deny.  But  the  mere  existence  of  the  fact  is  not  the  most  melancholy 
feature  of  the  case;  it  is  far  more  painful  to  see  mothers  listening  to  it, 
admitting  its  truth,  and  yet  calmly  and  dispassionately  choosing  to  make 
the  trial,  as  we  see  them  doing  constantly. 


PECULIAR    TO    WOMEN.  45 

When  the  day  arrives  in  which  our  young  growing  girls  are  educated 
physically  with  the  assiduity  and  system  now  bestowed  upon  their  mental 
culture  ;  when  mothers  desire  to  see  their  daughters  grow  up  strong,  well 
developed,  muscular  women,  and  not  merely  highly  educated  and  accom- 
plished valetudinarians,  one  of  the  most  prolific  of  the  predisposing  causes 
of  disease  of  the  genital  organs  will  have  disappeared.  No  amount  of 
mental  lahor,  no  degree  of  mental  culture  will  fit  a  woman  for  the  physical 
duties  of  wife  and  mother,  or  render  her  capable  of  bearing  children  com- 
petent to  resist  the  inroads  of  disease. 

In  a  woman  developed  by  this  pernicious  system,  the  physiological 
congestion  of  the  pelvic  organs  attending  ovulation  produces  pain  which 
is  known  as  "  neuralgic  dysmenorrhoea  ;"  ovulation  becomes  irregular  and 
abnormal,  favoring  the  development  of  subacute  ovaritis;  the  normal  hy- 
pertrophy of  the  uterus  consequent  upon  utero-gestation  slowly  and  imper- 
fectly passes  off,  subinvolution  often  remaining ;  while  the  enfeebled  mus- 
cular supports  of  the  heavy  organ  allow  it  to  lapse  from  its  position  and 
assume  that  of  flexion  or  version. 

Improprieties  of  Dress — The  dress  adopted  by  the  women  of  our  times 
may  be  very  graceful  and  becoming,  it  may  possess  the  great  advantages 
of  developing  the  beauties  of  the  figure  and  concealing  its  defects,  but  it 
certainly  is  conducive  to  the  development  of  uterine  diseases,  and  proves 
not  merely  a  predisposing,  but  an  exciting  cause  of  them.  For  the  proper 
performance  of  the  function  of  respiration,  an  entire  freedom  of  action 
should  be  given  to  the  chest,  and  more  especially  is  this  needed  at  the 
base  of  t he  thorax,  opposite  the  attachment  of  the  important  respiratory 
muscle,  the  diaphragm.  The  habit  of  contracting  the  body  at  the  waist 
by  tight  clothing  confines  this  part  as  if  by  splints;  indeed  it  accom- 
plishes just  what  the  surgeon  does  who  bandages  the  chest  for  a  fractured 
rib,  with  the  intent  of  limiting  thoracic,  and  substituting  abdominal  respi- 
ration. 

As  the  diaphragm,  thus  fettered,  contracts,  all  lateral  expansion  being 
prevented,  it  presses  the  intestines  upon  the  movable  uterus,  and  forces 
this  organ  down  upon  the  floor  of  the  pelvis,  or  lays  it  across  it.  In  addi- 
tion to  the  force  thus  exerted,  a  number  of  pounds,  say  from  five  to  ten, 
are  bound  around  the  contracted  waist,  and  held  up  by  the  hips  and  the 
abdominal  walls,  which  are  rendered  protuberant  by  the  compression  al- 
luded to.  The  uterus  is  exposed  to  this  downward  pressure  for  fourteen 
hours  out  of  every  twenty-four ;  at  stated  intervals  being  still  further 
pressed  upon  by  a  distended  stomach. 

In  estimating  the  effects  of  direct  pressure  upon  the  position  of  the  ute- 
rus, its  extreme  mobility  must  be  constantly  borne  in  mind.  No  more 
striking  evidence  of  this  can  be  cited  than  the  fact,  that  in  examining  it 
by  Sims's  speculum,  if  the  clothing  be  not  loosened  around  the  waist,  the 


46  ETIOLOGY    OF    THE    DISEASES 

cervix  is  thrown  so  far  back  into  the  hollow  of  the  sacrum  as  to  make  its 
engagement  in  the  field  of  the  instrument  often  very  difficult,  and  that 
attention  to  this  point  in  the  arrangement  of  the  patient  will  at  once  re- 
move the  difficulty.  While  the  uterus  is  exposed  by  the  speculum,  it  will 
be  found  to  ascend  with  every  expiratory  effort,  and  descend  with  every 
inspiration  ;  and  so  distinct  and  constant  are  the  rapid  alterations  of  posi- 
tion thus  induced,  that  in  operations  in  the  vaginal  canal  the  surgeon  can 
tell  with  great  certainty  how  respiration  is  being  affected  by  the  anaesthetic 
employed.  An  organ  so  easily  and  decidedly  influenced  as  to  position  by 
such  slight  causes  must  necessarily  be  affected  by  a  constriction  which,  in 
autopsy,  will  sometimes  be  found  to  have  left  the  impress  of  the  ribs  upon 
the  liver,  producing  depressions  corresponding  to  them. 

Corseting,  lacing,  and  the  wearing  of  tight  and  heavy  clothing,  also 
produce  a  deleterious  effect  in  quite  another  way.  Pressure  against  the 
abdominal  and  thoracic  muscles,  and  over  the  diaphragm,  produces  in 
them  a  partial  paresis.  This  impairs  abdominal  as  well  as  thoracic  respi- 
ration, to  a  great  extent  counteracts  the  important  retentive  power  of  the 
abdomen  over  the  pelvic  viscera,  and  allows  the  influence  of  gravitation, 
which  before  was  by  that  means  antagonized,  to  cause  displacement.  This 
result  of  a  pernicious  habit  cannot  be  too  thoroughly  appreciated  or  too 
much  insisted  upon.  So  prominent  is  it  in  etiology  that  I  might  well  have 
considered  it  under  the  head  of  exciting  causes.  By  the  direct  influences 
of  pressure  just  considered,  and  the  paresis  of  thoracic,  abdominal,  and 
diaphragmatic  muscular  fibres  now  alluded  to,  the  abdominal  viscera 
press  upon  the  growing  uterus  of  the  young  girl,  and  the  fundus  being 
bent  towards  the  cervix,  one  uterine  wall  develops  much  more  rapidly 
than  the  other,  and  at  puberty  the  menstrual  effort  finds  itself  interfered 
with  by  closure  of  the  cervical  canal,  and  an  origin  for  uterine  disease  is 
created  thereby. 

To  a  woman  who  ha3  systematically  displaced  her  uterus  by  years  of 
imprudence,  the  act  of  sexual  intercourse,  which,  in  one  whose  organs 
maintain  a  normal  position,  is  a  physiological  process  devoid  of  pathologi- 
cal results,  becomes  an  absolute  and  positive  source  of  disease.  The  axis 
of  the  uterus  is  not  identical  with  that  of  the  vagina.  "While  the  latter 
has  an  axis  coincident  with  that  of  the  inferior  strait,  the  former  has  one 
similar  to  that  of  the  superior.  This  arrangement  provides  for  the  passage 
of  the  male  organ  below  the  cervix  into  the  posterior  cul-de-sac,  the  cervix 
thus  escaping  injury.  But  let  the  uterus  be  forced  down,  as  it  is  by  the 
prevailing  styles  of  fashionable  dress,  even  to  the  distance  of  one  inch, 
and  the  natural  relation  of  the  parts  is  altered.  The  cervix  is  directly 
injured,  and  thus  a  physiological  process  is  insensibly  merged  into  one 
productive  of  pathological  results.  How  often  do  we  see  uterine  disease 
occur  just  after  matrimony,  even  where  no  excesses  have  been  committed. 
It  is  not  an  excessive  indulgence  in  coition  which  so  often  produces  this 


PECULIAR    TO    WOMEN.  47 

result,  but  the  indulgence  to  any  degree  on  the  part  of  a  woman  who  has 
distorted  the  natural  relations  of  the  genital  organs. 

But  this  is  by  no  means  the  only  method  by  which  displacement  of  the 
uterus  may  induce  disease  of  its  structures.  It  disorders  the  circulation  in 
the  displaced  organ,  and  produces  passive  congestion  and  its  resulting 
hypertrophy,  prevents  the  free  escape  of  menstrual  blood  by  pressing  the 
os  against  the  vagina,  creates  flexion,  causes  friction  of  the  cervix  against 
the  floor  of  the  pelvis,  and  stretches  the  uterine  ligaments  and  destroys 
their  power  and  efficiency. 

These  facts  should  be  carefully  borne  in  mind  by  the  physician  who 
attempts  to  relieve  uterine  displacements  by  the  use  of  pessaries.  If  he 
merely  replaces  the  displaced  organ  and  relies  for  its  support  upon  a  pes- 
sary, he  will  often  fail  in  accomplishing  the  desired  result.  He  is  striving 
at  great  disadvantage  with  a  short  lever  power  against  the  weight,  not  of 
the  uterus  alone,  but  of  the  super-imposed  viscera  pressed  downwards  by 
several  pounds  of  clothing,  which  add  their  weight  at  the  same  time  that 
they  constrict  the  waist  and  substitute  abdominal  for  thoracic  respiration. 
Thus  employed  the  pessary  will  often  give  great  pain,  and  so  injure  the 
parts  upon  which  it  rests  as  to  necessitate  removal,  and  the  practitioner 
will  find  himself  cut  off  from  one  of  his  most  valuable  resources.  Should 
he,  on  the  other  hand,  before  employing  a  pessary,  remove  all  constriction 
and  weight  from  the  abdominal  walls,  apply  a  well-fitting  abdominal  sup- 
porter over  the  hypogastrium  so  as  to  aid  the  exhausted  abdominal  mus- 
cles in  their  work,  keep  the  displaced  and  congested  uterus  out  of  the 
cavity  of  the  pelvis  by  a  tampon  of  medicated  cotton,  or  bring  Gravitation 
to  his  assistance  by  the  position  of  the  patient,  he  will  ordinarily  at  the 
end  of  a  week  be  able  to  employ  with  great  advantage  the  same  pessary, 
which  at  first  seemed  to  accomplish  evil  and  not  good. 

Imprudence  during  Menstruation  is  a  prolific  source  of  disease.  Some 
women,  through  ignorance,  many  through  recklessness,  and  a  few  from 
necessity,  go  out  lightly  clad  in  the  most  inclement  weather  during  this 
period,  and  many  suffer  in  consequence  from  violent  congestive  dysmenor- 
rhea, and  often  from  endometritis.  Every  practitioner  will  meet  with  a 
certain  number  of  cases  of  uterine  disease  which  have  this  origin,  and 
run  on  for  years,  ending,  perhaps,  in  parenchymatous  disease,  which  may 
prove  incurable. 

During  a  period  in  which  the  ovaries  and  uterus  are  intensely  engorged, 
in  which  the  surface  of  the  ovary  is  broken  through  by  the  escaping  ovule, 
and  the  nervous  system  is  in  an  unusual  state  of  excitability,  ordinary 
prudence  would  suggest  that  the  body  should  be  well  covered,  that  the 
congested  organs  should  be  left  at  rest,  and  that  exposure  to  cold  and 
moisture  should  be  sedulously  avoided.  I  need  not  say  that  these  rules 
are  commonly  neglected ;  and  in  evidence  of  the  fact  I  will  venture  the 


48  ETIOLOGY    OF    THE    DISEASES 

assertion  that,  on  this  very  day,  the  thermometer  15°  above  zero,  the 
skating  pond  of  our  park  contains  scores  of  delicate  and  refined  women 
who  are  showing  a  disregard  of  them  by  their  presence  there. 

The  immediate  result  of  exposure  during  menstruation  is  most  com- 
monly inflammation  of  the  mucous  membrane  of  the  uterus.  Such  an 
inflammation  once  excited  will  often  go  on  for  years  and  in  time  end  in 
parenchymatous  disease,  entailing  in  its  progress  dysmenorrhea,  sterility, 
pelvic  pain,  and  gastric  disorders,  which  impair  digestion  and  nutrition. 
Many  cases,  too,  of  pelvic  peritonitis,  cellulitis,  and  hematocele  develop  at 
this  trying  period  of  congestion  and  nervous  exaltation. 

Imprudence  after  Parturition No  sooner  does  fixation  of  the  impreg- 
nated ovum  upon  the  uterine  surface  occur  than  a  surprising  stimulation 
is  exerted  upon  the  fibre-cells  forming  part  of  the  uterine  parenchyma, 
which  grow  with  rapidity,  enlarging  the  organ,  pari  passu,  with  the 
requirements  of  its  increasing  contents.  After  the  expulsion  of  the 
embryo,  either  at  full  time  or  at  any  period  of  pregnancy,  the  fibres  thus 
developed  undergo  a  fatty  degeneration  and  absorption,  which  has  received 
the  name  of  involution.  This  process  occurs  rapidly  after  abortion,  but 
after  labor  at  term  it  requires  six  weeks  for  its  full  accomplishment.  In 
order  that  it  may  proceed  with  normal  rapidity  and  certainty,  perfect  rest 
is  essential ;  and  the  woman  who  rises  too  soon,  and  resumes  her  usual 
occupations,  while  the  lochial  discharge  is  still  existing,  risks  the  results 
of  interference  with  it.  Besides  this,  the  uterus  is  much  heavier  than 
usual,  and  the  additional  danger  of  the  induction  of  displacement  is  incurred 
by  too  early  exertion.  Lastly,  the  mucous  membrane  lining  the  cavity  of 
the  uterus  is  for  some  time  after  parturition  in  an  abnormal  state,  and  is 
peculiarly  liable  to  disease  from  exposure  to  cold  and  moisture.  A  very 
valid  objection  may  be  made  to  this  view,  that  in  the  lower  walks  of  life 
women  rise  after  labor,  and  attend  to  their  duties  with  impunity  on  about 
the  ninth  day,  and  yet  enjoy  a  marked  immunity  from  uterine  affections. 
This  is  true ;  but  let  it  be  remembered  that  they  are  unaffected  by  the 
influences  to  which  I  have  alluded  as  calculated  to  enfeeble  and  deteriorate 
their  generative  systems. 

Another  influence  connected  with  parturition,  which  develops  itself 
much  more  decidedly  among  the  higher  than  the  lower  classes,  is  the  per- 
nicious habit  of  tight  bandaging.  For  three  or  four  weeks  after  delivery 
the  nurse  commonly  applies  two  folded  towels  over  the  enlarged  uterus, 
and  by  powerful  compression  by  a  bandage  forces  the  organ  backwards 
into  the  hollow  of  the  sacrum.  This  is  supposed  to  preserve  the  comeliness 
of  the  figure,  and  the  reputation  of  many  a  nurse  rests  mainly  upon  the 
thoroughness  with  which  she  develops  an  influence  that  is  fruitful  of  evil 
in  displacing  an  enlarged  uterus  in  a  woman  who  for  a  fortnight  at  least 
lies  chiefly  upon  her  back.     That  a  well-fitting  bandage,  only  tight  enough 


PECULIAR    TO    WOMEN.  49 

to  give  support,  applied  after  delivery,  proves  a  source  of  comfort  to  the 
woman,  I  am  not  disposed  to  deny.  In  this  way  I  always  employ  one. 
But  I  feel  very  sure  that  a  great  deal  of  superstition  attaches  in  the  lying-in 
room  to  this  appliance,  hoth  as  a  means  of  preventing  deterioration  of  the 
figure,  and  post-partum  hemorrhage.  Uterine  contraction  should  be 
secured  by  vital,  not  mechanical  means,  and  no  amount  of  compression  by 
a  bandage  will  cause  the  over-distended  abdominal  muscles,  skin,  fascia?, 
and  areolar  tissue  to  return  to  their  original  condition.  Not  only  should 
tight  bandaging  be  avoided  after  delivery,  the  position  should  be  sys- 
tematically changed  at  intervals  from  the  dorsal  to  the  lateral  decubitus. 
I  am  convinced  that  uterine  displacement  is  one  of  the  most  fruitful  causes 
of  subinvolution.  As,  during  the  six  weeks  or  two  months  succeeding 
delivery,  the  process  of  retrograde  metamorphosis,  called  involution,  pro- 
gresses, the  uterus,  under  untoward  influences,  many  of  which  are  devel- 
oped by  the  routine  management  of  the  lying-in  chamber,  becomes  dis- 
placed. This  results  in  impeded  venous  return  from  its  tissues;  the 
process  of  involution  is  checked  ;  and  months  or  years  afterwards  the 
patient,  being  forced  to  apply  to  a  physician,  is  informed  that  she  has 
suffered  and  is  suffering  from  metritis  of'  a  chronic  character  of  which 
displacement  is  a  complication  or  result. 

Every  practitioner  frequently  hears  that  some  lady  has  been  injured  for 
life  "because  she  was  not  properly  bandaged  at  her  last  confinement," 
and  either  doctor  or  nurse,  possibly  both,  are  severely  censured  for  the 
culpable  neglect.  Too  often  such  censure  is  listened  to  in  silence,  and  the 
party  supposing  herself  injured  is  allowed  to  hold  the  same  opinion  still. 
It  is  the  duty  of  every  physician  to  inform  those  coming  under  his  influ- 
ence as  to  the  futility  of  trusting  to  the  obstetric  bandage,  or,  if  he  cannot 
conscientiously  do  so,  to  review  his  opinion  upon  the  subject,  and  see 
whether  his  own  confidence  is  not  misplaced. 

Non-recognition  or  Neglect  of  Injuries  due  to  Parturition "When  it 

shall  become  the  duty  of  the  obstetrician,  as  it  surely  soon  will  do  under 
the  influence  of  advancing  knowledge,  before  relinquishing  the  care  of 
the  recently  delivered  woman,  to  inform  himself  thoroughly  as  to  the  ex- 
istence of  laceration  of  the  cervix  or  perineum  ;  when  the  false  and  vicious 
doctrine  of  undervaluing  and  ignoring  these  grave  accidents  is  silenced 
forever  ;  and  when  a  neglect  of  their  early  repair  by  surgical  resort  shall 
be  regarded  as  a  flagrant  obstetrical  dereliction  ;  then  the  number  of  wo- 
men affected  by  pelvic  disorders  will  become  suddenly  and  wonderfully 
diminished.  The  time  for  this  is  now  at  hand,  and  the  profession  every- 
where should  raise  its  voice  in  a  matter  of  preventive  medicine  as  import- 
ant as  that  relating  to  the  infectious  diseases. 

So,  too,  is  the  time  at  hand  for  the  complete  obliteration  of  a  prevalent 
idea  in  the  public  mind,  that  the  functions  of  the  obstetrician  ordinarily 
4 


50  ETIOLOGY  OF  THE  DISEASES 

consist  in  watching  by  the  parturient  couch,  receiving  the  coming  child, 
and  creating  harmony  and  good  feeling  by  well-turned  compliments  and 
blandness  of  manner.  This  popular  idea  has  caused  and  causes  now  many 
a  tender  husband,  who,  were  he  about  to  select  a  coachman,  would  care- 
fully inquire  as  to  his  capacity  for  an  important  trust,  to  confide  his  wife 
at  the  mo3t  delicate  period  of  her  existence  to  the  hands  of  one  notoriously 
incompetent.  These  are  the  practitioners  who,  day  after  day,  year  after 
year,  send  forth  women  with  lacerated  cervices,  and  ununited  perineums, 
to  furnish  to  the  gynecologist  in  the  future  cases  of  uterine  engorgement, 
leucorrhoea,  prolapsus,  and  other  displacements,  and  cystitis,  and  a  long  list 
of  pathological  states  which  will  cling  to  them  for  life,  sapping  their  useful- 
ness, and  destroying  the  happiness  of  their  households. 

Prevention  of  Conception  and  Induction  of  Abortion Means  estab- 
lished for  the  accomplishment  of  the  first  of  these  ends  are  often  produc- 
tive of  uterine  disorder.  This  will  not  be  wondered  at  when  the  harshness 
of  some  of  them  is  borne  in  mind.  The  workings  of  nature  in  this,  as  in 
all  other  physiological  processes,  are  too  perfect,  too  accurately  and  deli- 
cately adjusted,  not  to  be  interfered  with  materially  by  the  clumsy  and 
inappropriate  measures  adopted  to  frustrate  them.  The  practice  is  be- 
coming exceedingly  common,  as  every  physician  is  aware,  so  common, 
indeed,  that  in  the  older  portions  of  this  country,  unfortunately,  it  must 
be  said,  in  the  more  civilized  and  educated,  it  is  by  no  means  usual  to 
meet  with  large  families  of  children.1 

The  fact  is  not  an  agreeable  one  to  deal  with,  and  the  facts  which  I  am 
citing  may  prove  unacceptable  to  many  of  my  countrymen,  but  it  is  one 
which  is  rapidly  assuming  proportions  which  must  influence  the  future 
population  of  our  country.  It  is  useless  to  ignore  it.  If  an  evil  is  to  be 
eradicated,  the  first  step  towards  such  a  consummation  is  its  recognition, 
and  what  class  of  men  can  more  immediately  and  more  effectually  grapple 
with  this  one  than  physicians  ? 

With  these  statements  we  leave  this  unattractive  subject  to  deal  with 
another,  which,  from  its  importance,  cannot  conscientiously  be  passed  over 
in  silence.  Statistics  showing  the  frequency  of  criminal  abortion  never 
have  been,  and  never  will  be  written,  for  the  crime  creeps  stealthily,  be- 
neath the  scrutiny  of  society.  That  this  criminal  practice  constitutes  a 
prolific  source  of  uterine  disease  no  one  engaged  in  gynecology  can  for  a 
moment  doubt.  So  impressed  with  this  fact  are  the  physicians  of  the 
United  States  that  some  years  ago,  at  its  meeting  in  New  York,  the 

1  Able  papers  upon  this  subject  appear  in  the  Boston  Gynecological  Journal  from 
the  pen  of  Prof.  D.  Humphrey  Storer,  and  in  the  Phila.  Medical  Times  from  that 
of  Prof.  Win.  Goodell. 


PECULIAR    TO    WOMEN.  51 

American  Medical  Association  offered  a  prize1  for  a  "  short  and  compre- 
hensive tract  for  circulation  among  females,  for  the  purpose  of  enlightening 
them  upon  the  criminality  and  physical  evils  of  forced  abortions." 

Marriage  with  Existing  Uterine  Disease — It  is  a  common  practice 
with  physicians  to  recommend  marriage  as  a  cure  for  uterine  disease. 
There  are  a  sufficient  number  of  abnormal  conditions  which  childbearing 
cures  to  make  the  practice  appear  legitimate,  but  a  vast  deal  of  harm  fre- 
quently results  from  it.  A  constricted  cervix  which  causes  dysmenorrhoea, 
a  pure  endometritis  of  neck  or  body,  or  an  inactive  state  of  the  ovaries 
which  results  in  amenorrhea,  may  be  relieved  by  the  parturient  act ;  but 
displacement,  peri-uterine  cellulitis  or  pelvic  peritonitis,  will  very  often 
produce  evil  results  after  labor,  and  very  generally  return  with  renewed 
violence  as  soon  as  involution  has  been  accomplished.  The  advice  is  too 
often  given  empirically,  and,  like  all  such  counsel,  is  hazardous  in  its  re- 
sults. My  experience  leads  me  to  fear  a  return  of  such  conditions  after 
childbearing,  even  in  a  patient  whom  I  considered  cured  at  the  time  of 
marriage. 

Insufficient  Food. — Many  diseases  of  the  uterus  are  established,  and  a 
still  larger  number  perpetuated,  by  impoverished  blood  and  the  disordered 
nerve  state  dependent  upon  spanasmia.  So  well  known  is  this  fact  that  a 
generous  diet  commonly  constitutes  an  important  element  of  treatment, 
and  its  result  in  improved  hematosis  is  hailed  as  the  harbinger  of  ap- 
proaching improvement.  The  tone  of  the  uterus,  that  is  its  muscular 
strength  and  power  of  resistance,  is  decidedly  affected  by  want  of  sufficient 
nutrient  material,  and  flexions  are  a  frequent  consequence,  as  Dr.  Graily 
Hewitt  has  ably  pointed  out ;  engorgement  of  the  mucous  membranes  of 
the  uterus,  Fallopian  tubes,  and  vagina,  are  favored  by  the  same  influence; 
and  it  is  beyond  doubt  that  a  feeble,  atonic  state  of  the  uterine  ligaments 
is  engendered  and  kept  up  by  it.  To  no  nation  in  the  Avorld  is  a  full 
supply  of  the  most  nutritious  food  so  attainable  as  to  the  inhabitants  of  the 
United  States.  And  yet  it  is  no  exaggeration  to  maintain  that  the 
American  woman,  except  in  our  cities,  is  at  least  half  starved.  She 
suffers  not  from  an  enforced  but  a  voluntary  starvation,  which  however 
none  the  less  impoverishes  her  blood  and  impairs  her  nerve  power.  Let 
any  one  travel  through  our  farming  regions  and  examine  closely  the 
women  with  whom  he  meets,  and  he  must  admit  that  the  robust,  buxom, 
florid  lass  and  matron  is  the  exception ;  the  pale,  lank,  and  emaciated, 
the  rule. 

1  The  prize  thus  offered  was  awarded  to  Prof.  H.  R.  Storer,  of  Boston,  for  an 
able  essay,  entitled  "Why  Not  f" 


52  ETIOLOGY  OF  THE  DISEASES 

These  women  are  not  overworked,  for  this  country  knows  no  hard- 
worked  peasantry.  They  are  under-fed,  however,  from  their  cradles  to 
their  graves.  It  must  be  remembered  that  it  is  not  merely  material  in- 
troduced into  the  stomach  which  nourishes  the  body,  but  the  introduction 
of  material  capable  of  making  blood  of  good  quality  which  does  so.  The 
eating  of  salt  fish  and  meats  in  place  of  fresh,  the  drinking  of  large 
amounts  of  tea  in  place  of  milk  and  malt  liquors,  and  the  consumption  of 
incalculable  amounts  of  the  noxious  and  inevitable  pie  of  the  Eastern 
States  in  place  of  bread  and  nutritious  puddings,  will  never  answer  the 
requirements  of  nutrition  until  the  laws  which  govern  that  process  are 
altered. 

The  American  travelling  in  Great  Britain  is  always  struck  by  the  large 
amounts  of  nutritious  food,  of  malt  liquors,  and  of  the  products  of  the 
dairy  which  are  consumed  as  well  as  by  the  amount  of  time  given  to  their 
consumption,  and  very  often  he  plumes  himself  upon  the  more  elegant 
habits  of  his  own  country.  In  vain  do  we  look  among  our  women  for 
justification  for  such  self-congratulation,  and  most  earnestly  would  we  urge 
an  imitation  of  customs  which  would   greatly  improve  our  own  condition. 

Habitual  Constipation — A  large  proportion  of  women  who,  after  puberty, 
marriage,  and  maternity,  suffer  from  uterine  disease  do  so  in  consequence 
of  deformities  of  the  uterus  developing  between  the  period  of  infancy  and 
that  of  womanhood.  One  of  the  most  frequent  and  obstinate  of  these  is 
cervical  anteflexion.  In  this  state  the  body  of  the  uterus  does  not  alter 
its  position,  but  the  cervix  is  bent  sharply  forwards,  creating  a  stricture 
at  or  near  the  os  internum  uteri,  and  causing  obstruction  to  the  escape  of 
fluids  from  the  uterus  and  interference  with  its  venous  circulation.  The 
habit  of  allowing  large,  hard  masses  of  fecal  matter  to  remain  not  only 
for  days  but  for  a  week  at  a  time  in  the  rectum,  as  many  women  do,  con- 
tributes largely  to  the  occurrence  of  this  deformity  in  the  soft,  pliable, 
growing  uterus  of  girlhood. 

Alone  it  is  sufficient  to  bend  the  uterus  and  give  it  the  shape  of  a  gourd, 
but,  combined  with  pressure  from  above  by  tight,  heavy  clothing  con- 
stricting the  waist,  it  is  not  astonishing  that  it  very  often  produces  this 
common  disorder  of  the  shape  of  the  organ.  Once  produced  it  is  a  condi- 
tion which  pretty  surely  results  in  endometritis,  dysmenorrhea,  and  ste- 
rility, and  it  is  one  rarely  remediable  except  by  resort  to  surgery. 

Let  me  present  a  picture,  simple  and  unexaggerated  in  its  details,  of 
millions  of  our  women  who  are  exposed  to  the  baneful  influences  which  I 
have  endeavored  to  portray.  The  woman  is  flat-chested,  slightly  round- 
shouldered,  and  thin  almost  to  emaciation.  Her  hands  and  feet  are  cold, 
and  her  facies  is  not  one  suggestive  of  hilarity  or  buoyancy  of  spirit. 
Auscultate  the  thoracic  organs,  and  a  slight  basic  murmur  will  be  heard 
over  the  heart,  and   the  respiration  will  be  found  feeble   and  inefficient. 


PECULIAR    TO    WOMEN.  53 

Tell  the  patient  to  inflate  the  lungs  fully,  and  the  effort  is  so  poor  an  one 
that  it  is  seen  at  once  that  a  full  inspiration  is  a  rare  matter  with  her. 
She  craves  such  stimulants  as  tea,  and  desires  as  food  articles  which  are 
sweet.  The  howels  are  almost  invariably  constipated,  and  an  examina- 
tion of  the  skin  shows  that  it  is  inactive,  and  that  its  vessels  are  not  tilled 
with  red  blood,  but  shrunken  and  atonic. 

She  is  nevertheless  in  excellent  health,  does  a  large  amount  of  work  in 
her  house,  and  perhaps  for  a  long  lifetime  fulfils  all  the  requirements  of 
her  existence.  So  she  willingly  allows  her  daughters  to  follow  in  her 
footsteps.  And  yet  how  thoroughly  is  this  woman  fulfilling  every  indica- 
tion which  is  necessary  to  cause  her  to  fall  an  easy  prey  to  disease  of  the 
sexual  organs  as  to  that  of  any  other  organ  in  the  body ! 

The  interdependence  of  the  various  physiological  processes  one  upon 
the  other  is  very  striking.  Primary  nutrition  keeps  the  blood  in  healthy 
state,  respiration  keeps  it  in  active  circulation,  and  action  of  the  muscles 
stimulates  and  makes  perfect  the  flow  through  the  capillary  vessels  of  the 
skin,  liver,  kidneys,  and  all  the  other  organs  of  the  body.  Derangement 
in  any  one  of  these  processes  creates  disorder  in  others.  Impoverished  blood 
entails  imperfect  circulation,  deficient  respiratory  effort  furthers  this,  and 
an  inactive  state  of  the  muscles  tends  to  production  of  local  hyperemia  by 
allowing  blood  stasis  in  the  deeper  parts  of  the  body.  All  this  renders 
excretion  inefficient,  and  the  nerve  centres  soon  feel  the  benumbing  influ- 
ence of  a  slow  toxaemia.  It  is  evident  that  the  influences  which  I  have 
mentioned  tend  very  decidedly  to  disorder  the  system  in  this  way. 

This  completes  the  list  of  those  influences  which,  in  my  estimation, 
most  markedly  predispose  to  disease  of  the  female  genitalia  in  the  United 
States.  In  reviewing  them  I  trust  that  I  have  not  spoken  in  a  tone  of 
exaggeration  of  any  one  of  them. 

There  are  two  points  in  this  connection  which  I  would  earnestly  insist 
upon,  and  concerning  which  I  feel  that  the  medical  profession  is  greatly 
at  fault.  The  first  is  the  prevalent  idea  that  there  is  in  woman  an  inhe- 
rent tendency  to  disease  of  the  sexual  organs,  that  she  is  born  to  these 
affections  "as  the  sparks  fly  upwrards,"  and  that  an  entire  immunity  from 
them  is  a  lucky  circumstance  which  is  rather  a  cause  for  surprise.  The 
second  is  the  belief  that,  these  disorders  being  contracted,  not  from  avoid- 
able but  from  inevitable  causes,  the  woman  herself  is  not  responsible  for 
them.  Once  falling  a  victim,  she  immediately  puts  herself  under  the  care 
of  a  physician,  and  then  very  likely  follows  a  lengthy  and  tedious  course 
of  local  treatment. 

Surely  one  of  the  highest  duties  of  the  physician  is  to  disseminate  cor- 
rect views  upon  these  points ;  one  of  his  greatest  derelictions  endorsing 
them  by  tacit  consent. 

I  shall  deal  very  cursorily  with  the  exciting  causes  of  these  diseases,  for 


54  GENERAL    CONSIDERATIONS    UPON 

the  reason  already  given.  I  would  not,  indeed,  have  alluded  to  them 
here  were  it  not  that  the  opportunity  for  enumerating  them  in  this  con- 
nection appeared  to  be  too  important  a  one  to  be  lost. 

The  chief  of  these  may  thus  be  tabulated: — 

1st.  Injuries  inflicted  by  parturition — e.  g.,  laceration  of  cervix  and 
perineum ;  pudendal  and  sub-peritoneal  hematocele ;  and  inversion  of  the 
uterus. 

2d.  Derangements  of  involution — e.  g.,  subinvolution  of  uterus,  vagina, 
perineum,  and  uterine  ligaments  ;  superinvolution  of  uterus;  fungoid  de- 
generation of  the  endometrium;  retention  of  foetal  envelopes;  displacements 
of  the  uterus. 

3d.  Congenital  and  infantile  anomalies  in  shape,  proportions,  and  posi- 
tion of  genitalia — e.  g.,  flexion ;  undeveloped  state  of  cervix,  of  body  of 
uterus,  or  of  both ;  contractions  of  cervical  canal ;  absence  or  imperfect 
development  of  ovaries,  and  similar  imperfections  of  the  vagina. 

4th.  Sudden  violent  and  unaccustomed  efforts  producing  flexions,  ver- 
sions, and  prolapse. 

oth.  The  development  of  neoplasms  in  connection  with  any  of  the 
genital  organs — e.  g.,  fibroids  or  cysts  of  the  uterus,  vagina,  or  ovaries; 
adenoma,  sarcoma,  cancer,  etc. 

Gth.  Deposits  of  lymph  throughout  the  pelvis  from  general  peritonitis — 
causing  displacements  of  uterus  and  ovaries;  ovarian  engorgement  and 
neuralgia ;  congestion  of  all  the  pelvic  organs. 

7th.  Local  treatment,  and  examination  by  sounds,  tents,  etc. — causing 
peritonitis,  septicaemia,  and  cellulitis. 

8th.  Contamination  by  gonorrhocal  or  syphilitic  virus — causing  endome- 
tritis, salpingitis,  pelvic  peritonitis,  and  development  of  syphilitic  abrasions 
and  neoplasms. 

9th.  Means  adopted  for  prevention  of  conception  and  production  of 
criminal  abortion — causing  endometritis,  granular  degeneration,  pelvic  pe- 
ritonitis and  cellulitis,  fungoid  degeneration  of  endometrium,  septicaemia, 
and  retention  of  the  foetal  envelopes. 


CHAPTER   III. 

GENERAL  CONSIDERATIONS  UPON  UTERINE  PATHOLOGY  AND 
TREATMENT. 

Let  us  suppose  that  a  woman,  born  of  a  mother  who  has  transmitted  to 
her  a  rather  feeble  constitution,  lives  such  a  life  as  to  expose  herself  to 
enfeeblcment  of  the  nerve  power,  impoverishment  of  the  blood,  and  local 


UTERINE    PATHOLOGY    AND    TREATMENT.  55 

disorders  of  the  circulation,  from  the  predisposing  causes  mentioned  in 
the  last  chapter.  These  alone  are  sufficient  to  establish  in  her  disease  of 
the  sexual  organs;  or,  if  they  do  not  do  so,  one  of  the  exciting  causes 
enumerated  may  supervene,  and,  falling  upon  well-prepared  ground,  the 
seeds  of  disease  thus  sown  thrive  luxuriantly.  Let  us  consider  the  patho- 
logical steps  by  which  the  various  pelvic  diseases  peculiar  to  her  sex  are 
developed. 

Nothing  more  decidedly  retards  the  progress  of  gynecology,  lowers  it 
as  a  special  study  in  the  eyes  of  the  sister  departments,  and  fans  the  dying 
flame  of  a  prejudice  with  which  it  has  been  able  successfully  to  contend 
only  during  the  past  half  century,  than  the  unsettled  state  of  uterine 
pathology.  In  general  medicine,  in  surgery,  and  in  all  other  special 
departments,  the  study  of  pathology  is  made  the  keystone  of  the  arch 
which  supports  them ;  and  observers  seem  willing  to  agree  as  to  fixed 
principles  concerning  it.  In  gynecology,  this  whole  subject  presents  the 
melancholy  aspect  of  uncertainty  and  dissension.  Many  of  its  votaries, 
instead  of  taking  broad  and  strong  views,  become  the  partisans  of  some 
special  dogma  or  theory,  which  is  warmly  attacked  by  others  who  hold 
some  view  equally  narrow,  incomprehensive,  and  exclusive. 

As  a  result  of  this  state  of  pathological  confusion  among  the  leading 
minds  devoted  to  the  department,  every  newly-fledged  specialist  feels 
warranted  in  elaborating  and  maintaining  a  theory  of  his  own ;  or,  in 
attaching  himself  to  one  of  the  many  which  present  themselves  for  his 
choice. 

All  must  admit  that  to  this  department  to-day  as  many  able,  zealous, 
and  industrious  laborers  are  devoted,  as  to  any  other  in  medicine.  Why 
should  such  a  body  weaken  its  influence  by  adherence  to  dissentient  and 
partisan  views?  Why  is  one  impelled  to  entertain  the  view  that  inflam- 
mation of  the  parenchyma  plays  the  important  part  of  moving  cause  in 
uterine  disorders;  another  that  displacements  of  the  uterus  do  so;  another 
that  the  chief  trouble  consists  in  an  irritation  or  hyperesthesia  in  the 
uterine  nerves;  another  that  catarrhal  inflammation  of  the  uterine  mucous 
membrane  is  the  origin  of  most  of  its  disorders  ;  while  still  another  attrib- 
utes to  the  inefficient  restoration  of  the  uterus  after  the  structural  changes 
due  to  utero-gestation,  the  most  important  role?  To  one  who  calmly  and 
dispassionately  considers  the  subject,  not  in  the  study,  but  by  the  bedside, 
and  who  goes  to  it  with  a  mind  free  from  prejudice,  and  eager  for  the 
discovery  of  truth,  it  appears  to  me  that  it  must  in  time  become  evident 
that  truth  lies  not  in  any  one  of  these  theories,  but  is  to  be  found  to  a  cer- 
tain extent  in  each.  No  pathologist  claims  that  hepatic,  or  cardiac,  or 
renal  disease  has  always  the  same  pathological  origin;  why  should  any 
one  expect  to  find  for  uterine  disorders  a  universal  pathogenic  factor? 

At  no  period  in  modern  times  has  this  department  been  so  favorably 
and  respectfully  regarded,  by  the  science  of  which  it  is  a  part,  as  at  pre- 


56  GENERAL    CONSIDERATIONS    UPON 

sent.  Now,  then,  has  the  time  arrived  when  every  one  of  its  well-wish- 
ers should  strive  to  obliterate  all  factions  and  parties,  to  free  it  from  dog- 
mas and  narrow  views,  and  place  it  where  it  should  always  have  stood, 
upon  the  broad  platform  of  an  enlightened  pathology. 

That  the  uterus  should  perform  its  functions  efficiently  and  naturally,  it 
is  essential,  1st,  that  its  innervation  and  circulation  should  be  normal  ; 
2d,  that  its  structure  should  be  unaltered  in  character  and  proportions ; 
and  3d,  that  no  decided  and  permanent  change  should  have  occurred  in 
its  position.  An  abnormal  state,  developing  in  connection  with  any  one 
of  these  essential  conditions,  may  derange  the  functional  powers  of  this 
important  viscus,  and  demonstrate  itself  by  symptoms  which  produce 
greater  or  less  discomfort  to  the  woman.  When,  as  very  often  happens, 
the  first  evil  produces  others,  until  at  last  all  three  conditions  are  inter- 
fered with,  the  gravity  of  the  symptoms  increases  with  simultaneous  in- 
crease in  their  number  and  variety.  Sometimes  the  first  link  in  the  chain 
of  morbid  action  is  an  altered  condition  of  the  nerves  governing  circula- 
tion, some  general  or  local  condition  reflecting  itself  upon  these  regulators 
of  nutrition  ;  as  a  consequence,  an  afflux  of  blood  takes  place  to  the  ute- 
rine mucous  membrane,  and  its  vessels  become  distended,  and  in  time 
dilated.  This  lasts  for  a  variable  time,  when  the  second  link  is  furnished 
in  this  manner :  an  excessive  degree  of  nutrition  is  supplied  to  the  sub- 
jacent connective  or  areolar  tissue  of  the  organ,  and  its  size  and  weight 
increase.  Then  the  third  link  rapidly  develops  itself.  The  uterus  now 
being  heavier  than  normal,  its  natural  and  hitherto  sufficient  supports  are 
insufficient  for  its  maintenance  in  position,  and  it  descends  in  the  pelvis, 
sometimes  so  as  to  alter  the  direction  of  its  axis,  and  protrude  between  the 
labia  majora ;  at  other  times  its  axis  is  not  changed  in  its  descent,  and 
then  the  cervix,  striking  against  the  curved  surface  of  the  sacrum,  is  bent 
forwards  so  as  to  offer  an  obstruction  to  the  escape  of  menstrual  blood  ;  at 
others,  the  fundus  falls  forwards,  laterally,  or  backwards,  either  bending 
upon  the  neck,  or  by  its  displacement  forcing  this  part  out  of  position 
likewise.  Then  appear,  as  symptoms  of  this  threefold  disturbance,  leucor- 
rhoea,  backache,  dysmenorrhea,  difficulty  in  locomotion,  and  the  long  list 
of  discomforts  to  which  women  thus  affected  are  liable. 

This,  however,  is  by  no  means  always  the  sequence  of  events.  Some- 
times the  uterus  enlarged  by  utero-gestation  does  not  return  to  its  original 
small  size,  but  remaining  large  and  heavy,  it  falls  from  its  place  in  conse- 
quence,  and  this  disorder  of  position  reacts  upon  the  other  two  conditions 
which  I  have  stated  are  essential  to  health — normal  innervation  and  cir- 
culation, and  an  unaltered  state  of  the  structure  of  the  organ. 

A^ain,  a  uterus  may  be  in  a  perfectly  normal  state  in  every  respect, 
when  suddenly  it  becomes  retroverted.  As  a  consequence,  innervation 
and  circulation  are  at  once  disturbed,  congestion  occurs,  a  hypergenesis  of 
tissue  gradually  takes  place,  and   thus  what  was  originally  merely  a  dis- 


UTERINE    PATHOLOGY    AND    TREATMENT.  57 

placement  becomes  a  condition  of  congestion,  enlargement,  and  chronic 
catarrh. 

The  position  which  I  assume,  with  reference  to  the  pathological  scries 
which  may  result  in  confirmed  uterine  disease,  is  this:  that  the  pelvic 
organs  of  a  woman  who  has  hitherto  been  in  perfect  health  may  become 
gradually  or  suddenly  diseased  by  one  of  the  three  following  abnormal 
developments  in  the  uterus:  1st,  disorder  in  innervation  and  circulation; 
2d,  change  in  Quantity  of  connective  or  muscular  tissue;  3d,  change  in 
position.  I  assume,  furthermore,  that,  the  first  here  mentioned  being  the 
primary  lesion,  the  second  and  third  may  result  from  it;  that,  the  second 
being  the  primary  lesion,  as  in  subinvolution  or  the  development  of  neo- 
plasms, the  first  and  third  may  result  from  it;  and  that,  the  third  primarily 
showing  itself  in  a  perfectly  healthy  organ,  the  first  and  second  may  be 
its  consequences. 

Let  us  now  proceed  one  step  further.  Those  primary  pathological 
conditions  which  most  commonly  produce  disorder  in  the  three  elements 
which  I  have  mentioned,  may  be  said  to  constitute  the  especial  factors  of 
uterine  disease.     What  are  they? 

1st.   Catarrhal  inflammation  of  the  lining  membrane. 

2d.  Prolonged  congestion  of  uterine  tissues. 

3d.  Excessive  growth  of  connective  or  muscular  tissues. 

In  the  beginning  one  only  may  exist,  uterine  catarrh,  for  example;  in 
time  this  may  induce  another,  congestion  in'  the  parenchyma;  and  still 
later,  this  excessive  blood  supply  may  result  in  a  third,  hypergenesis  of 
connective  tissue.  Whatever  then  tends  to  induce  and  keep  up  any  one 
of  these  three  morbid  states,  tends  directly  to  the  establishment  of  confirmed 
uterine  disease,  and  the  consideration  of  this  point  brings  us  to  the  inves- 
tigation of  the  individual  pathological  agencies  which  ordinarily  produce 
such  a  result. 

1st.  In  the  very  large  majority  of  cases  of  uterine  disease,  the  first  link 
in  the  morbid  chain  is  subinvolution,  which  produces  as  direct  conse- 
quences, passive  congestion,  hypersecretion  by  lining  membrane,  menstrual 
disorders,  displacements,  sterility,  and  interference  by  pressure  with  neigh- 
boring organs. 

2d.  A  certain  number  of  cases  is  produced  by  disordered  uterine  circu- 
lation and  innervation,  the  results  of  displacement  of  the  uterus,  either  as 
a  whole  or  by  bending  of  itself  upon  its  axis.  Such  displacement  or  dis- 
tortion induces  passive  congestion,  hypergenesis  of  tissue,  dysmenorrhoea, 
sterility,  and  endometritis. 

3d.  A  certain  number  of  cases  arises  from  primary  catarrhal  inflamma- 
tion of  the  lining  membrane  of  the  uterus  itself.  This,  commencing  as  an 
entity,  results  in  hypergenesis  of  tissue,  displacements,  menstrual  disor- 
ders, and  sterility. 


58  GENERAL    CONSIDERATIONS    UPON 

4th.  In  a  number  of  cases  by  no  means  small,  the  circulation,  innerva- 
tion, and  size  of  the  uterus  are  interfered  with  by  obstruction  to  the  escape 
of  menstrual  blood.  Such  obstruction  distends  the  uterine  cavity  by  the 
imprisoned  menstrual  discharge,  inflames  its  lining  membrane,  and  results 
in  leueorrhcea,  dysmenorrhea,  hematocele,  and  flexions. 

5th.  In  some  cases  the  uterus  is,  by  sympathy  with  diseased  ovaries, 
kept  in  a  condition  of  exalted  innervation  and  deranged  circulation,  which, 
in  time,  eventuates  in  congestion  of  the  whole  organ  and*  hypersecretion 
by  the  mucous  lining.  As  consequences  of  these  states,  there  appear  as 
symptoms,  leucorrhoea,  menstrual  disorders,  displacements,  sterility,  etc. 

6th.  The  development  of  benign  or  malignant  growths,  consisting  of 
hyperplasia  of  one  or  more  of  the  uterine  elements,  often  deranges  the 
innervation,  circulation,  and  proportionate  weight  of  the  uterus,  and  results 
in  displacements,  sterility,  menstrual  disorders,  leucorrhoea,  pelvic  pains, 
mechanical  interference  with  surrounding  organs,  etc. 

7th.  The  uterus,  although  not  primarily  affected,  may  become  displaced 
and  congested  from  interference  by  contracting  lymph,  exuded  in  contact 
with  it  and  over  its  surface,  as  a  consequence  of  pelvic  peritonitis.  Such 
displacement  and  congestion  may  result  in  excessive  growth  of  tissue  and 
endometritis. 

8th.  Disease  not  only  of  the  neck  but  of  the  body,  and  not  only  of  the 
mucous  membrane  but  of  the  proper  tissue  of  the  organ,  is  often  induced 
by  laceration  of  the  cervix,  which  results  in  eversion,and  the  exposure  of 
a  large  and  vulnerable  surface  to  friction  and  injury  during  coition  and 
exercise. 

9th.  The  genital  organs  are  often  kept  in  a  state  of  erethism  and  hyper- 
emia by  a  neurosis,  such  as  vaginismus,  or  a  point  of  intense  nervous 
excitement,  such  as  fissure  of  the  anus,  which  may  develop  into  absolute 
disease. 

Let  the  pathological  state  which  establishes  the  disorder  be  what  it  may, 
after  it  has  continued  for  some  time  and  its  instrumentality  has  resulted 
in  fixed  disease,  the  following  symptoms  develop  as  characteristic  of  such 
disease:  leucorrhoea;  menstrual  disorders;  pain  in  back,  loins,  and  pelvis; 
sterility;  hysteria  or  nervous  symptoms;  gastric,  intestinal,  and  vesical 
derangements,  etc.     They  are  confined  to  none,  but  in  time  mark  all. 

That  congestion  constitutes  one  of  the  pathological  steps  in  the  process 
is  beyond  question ;  but  how  short-sighted,  how  superficial,  to  make  it  a 
sole  factor,  to  declare  it  to  be  "fons  et  origo"! 

With  these  facts  before  him,  the  student  may  well  ask,  how  any  logical 
mind  could  consent  to  adhere  to  an  exclusive  pathological  doctrine,  ignor- 
ing or  denying  others  of  unquestionable  importance  and  significance?  It 
has,  I  think,  been  done  by  confounding  cause  and  effect.  He  whose  mind 
is  hampered  by  the  theory  of  inflammation  will  find  it  in  every  case  of 
long  standing,  in  the  mucous  membrane,  for  congestion  of  this  produces 


UTERINE    PATHOLOCJY    AND    TREATMENT.  59 

hypersecretion;  and  in  the  parenchyma,  because  hypernutrition  in  this 
part  has  resulted  in  hypergenesis  of  tissue.  The  uterus  is  large,  tumefied, 
secreting  excessively,  and  tender  to  the  touch;  all  these  prove  for  him 
"inflammation"  to  exist.  In  the  great  majority  of  cases  in  which  a  dis- 
eased uterus  is  examined  after  it  has  been  in  an  abnormal  condition  for  a 
long  time,  the  following  physical  signs  will  be  discovered: — 

1st.  The  uterus  will  be  larger  than  normal. 

2d.   Catarrh  of  the  lining  membrane  will  exist. 

3d.  The  vaginal  face  of  the  cervix  will  be  in  a  granular  condition. 

4th.  The  uterus  will  be  displaced. 

5th.  The  ovaries  will  be  found  slightly  enlarged  and  sensitive. 

Here  are  five  theories  offering  themselves  for  adoption,  and  in  a  conclave 
of  five  consultants,  each  might  hold  an  unassailable  ground,  and  each 
might  possibly  be  right.  But,  as  no  one  has  the  key  to  the  progressive 
development  of  the  complex  condition,  no  one  can  prove  himself  so.  Ac- 
cording to  my  observation,  the  analysis  of  this  collection  of  morbid  states, 
which  most  frequently  furnishes  the  key  to  their  solution,  is  this: — . 

Involution  of  the  uterus  was  interfered  with  some  years  before,  and 
subinvolution  existed  for  a  while,  and  gradually  resulted  in  areolar  hyper- 
plasia -,1  this  soon  resulted  in  displacement,  which  impeded  venous  action ; 
from  this,  a  uterine  catarrh  arose,  which  excoriated  by  its  discharge  the 
vaginal  face  of  the  cervix;  from  this  cause,  combined  with  friction,  gran- 
ular degeneration  took  place;  and  the  irritation  transmitted  by  this  com- 
plication of  irritating  influences  created  enlargement  and  sensitiveness  of 
the  ovaries. 

I  say,  that,  according  to  my  experience,  the  most  common  factor  of  this 
series  is  subinvolution ;  but  I  do  not  say  that  it  is  the  universal  factor. 
It  may  be  that  all  these  lesions  arose  from  congestion  due  to  retroversion 
which  has  been  neglected,  and  has  long  prevented  free  venous  return. 
Or,  perchance,  the  large  granular  surface,  which  has  been  called  an  "  in- 
flammatory ulcer,"  is  an  eversion  of  the  cervical  mucous  membrane  due 
to  rupture  of  the  cervix,  which  occurred  five  years  ago  in  parturition,  and 
has  kept  up  nervous  irritation  and  hyperemia,  which  have  resulted  in  all 
these  "signs  of  inflammation." 

Impressed  by  the  fact  that,  with  many  of  the  physical  and  rational  signs 
of  inflammation,  the  enlarged,  sensitive,  and  engorged  uterus  is  not  in- 
flamed ;  one  party  has  endeavored  to  cut  the  gordian  knot  by  styling  the 
anomalous  state  one  of  "irritability."  But  the  term  was  badly  chosen, 
and  its  introduction  has  accomplished  more  of  confusion  than  of  simplifi- 
cation, nor  have  the  profession  generally  been  willing  to  accept  a  name 

1  Hypertrophy  signifies  excessive  growth  or  enlargement  of  a  tissue  already 
existing  :  hyperplasia  signifies  the  development  of  new  tissue. 


60  GENERAL    CONSIDERATIONS    UPON 

signalizing  the  nervous  condition  alone  for  a  state  characterized  by  con- 
gestion, hypergenesis  of*  tissue,  and  coincident,  probably  resulting,  nervous 
exaltation. 

But,  it  may  be  asked,  is  not  this  condition  of  enlargement  of  the  uterus 
after  all  a  state  of  inflammation,  of  chronic  metritis,  however  it  may  have 
arisen?  I  answer,  no  more  a  condition  of  chronic  inflammation  than  is 
the  enlargement  of  the  tonsils  which  lasts  for  years  in  children;  or  than 
the  tender,  enlarged  spleen,  the  ague  cake  of  malarial  poisoning;  or  than 
the  enlarged  testicle  of  syphilis.  I  do  not  deny  the  name  and  character 
of  inflammation  to  suppurative  tonsillitis  or  quinsy,  to  the  orchitis  of 
gonorrhoea  or  even  to  that  very  rare  disease  splenitis,  which  sometimes 
ends  in  suppuration.  Let  the  unprejudiced  reader  reply  to  this  question 
from  his  own  observation :  does  the  state  of  the  uterus  which  we  are  con- 
sidering most  resemble  the  former  or  the  latter  of  these  pathological 
states?     I  cannot  doubt  his  reply. 

These  remarks  apply  not  only  to  the  partisans  of  the  dogma  of  inflamma- 
tion, but  to  those  of  all  the  others  which  have  been  adopted.  He  who 
wishes  to  sustain  his  views  and  his  party  by  finding  displacement  will 
almost  always  do  so,  for  a  heavy  uterus,  which  was  in  normal  position  in 
the  beginning,  generally  falls  from  its  place  in  time;  he  who  looks  for 
uterine  catarrh  will  likewise  be  gratified,  for  a  congested  mucous  mem- 
brane always  gives  forth  an  excessive  secretion ;  and  even  he  who  will  be 
satisfied  with  nothing  but  ovarian  disease  will  often  be  able  to  sustain  his 
theory,  for  chronic  uterine  disorder  is  very  apt  to  affect  in  time  these 
organs,  which  are  so  intimately  in  sympathy  with  the  uterus. 

Prognosis  in  Uterine  Affections — There  is  no  organ  of  the  body  the 
diseases  of  which  offer  greater  difficulties  in  prognosis  than  those  of  the 
uterus.  So  much  depends  upon  the  habits  of  the  patient,  the  injurious 
influences  to  which  she  is  exposed,  and  the  faithfulness  with  which  she 
follows  out  the  directions  of  the  physician,  that  often  very  little  can  be 
predicted,  very  little  promised  with  any  certainty.  The  error  into  which 
the  incautious  practitioner  is  most  likely  to  fall  is  that  of  predicting  a  cure 
at  too  early  a  period,  and  fixing  some  definite  time  for  its  accomplishment. 
The  patient  may  declare  that  she  and  her  friends  will  be  satisfied  even  if 
the  limit  be  fixed  not  by  months  but  by  years,  nevertheless  she  is  desirous 
of  knowing  when  she  may  confidently  expect  a  cure.  The  answer  to  this 
question,  not  in  the  lesser  interest  of  the  practitioner,  but  in  the  greater 
one  of  the  patient,  must  often  be,  that  no  such  time  can  possibly  be  deter- 
mined upon.  In  some  cases  it  becomes  necessary  to  state  further  that 
not  only  is  the  time  but  the  certainty  of  complete  cure  doubtful;  that 
local  treatment  will  cause  pain,  may  result  in  danger,  and  may  absolutely 
aggravate  the  existing  symptoms. 

Another  point  which  influences  prognosis  is  this:  in  the  management 
of  uterine  diseases  it  is  of  primary  importance  that  the  practitioner  should 


UTERINE    PATHOLOGY    AND    TREATMENT.  61 

enlist  the  interest  and  co-operation  of  his  patient.  Should  she  be  apa- 
thetic with  regard  to  the  result,  or  even,  having  begun  treatment  with 
enthusiasm,  become  disaffected  from  any  cause,  his  duties  will  probably 
prove  irksome,  annoying,  and  fruitless.  For  this  reason  he  should  be 
cautious  in  urging  with  too  great  earnestness  the  adoption  of  local  treat- 
ment. 

In  view  of  this,  and  the  additional  fact  that  treatment  may  extend  over 
months  before  a  cure  is  effected,  the  physician  should  avoid  all  resources 
which  by  their  uncleanliness  or  disagreeable  nature  may  disgust  a  refined 
patient,  or  make  her  rather  willing  to  bear  her  disease  than  the  means 
adopted  for  its  cure.  If  such  means  will  be  very  likely  to  give  relief, 
they  should  of  course  be  employed;  but  if,  as  is  the  case  with  many  of 
them,  their  efficacy  be  extremely  doubtful,  they  should  not  be  insisted 
upon.  For  example,  if  a  lively,  fastidious  lady  were  called  upon,  for  the 
relief  of  an  endometritis  which  is  not  in  itself  very  annoying,  to  forego 
society  and  spend  most  of  her  time  in  bed,  to  fill  the  vagina  daily  with  a 
semi-solid  mass  of  powdered  linseed  after  the  method  of  Melier,  to  rub 
mercurial  ointment  over  the  hypogastrium,  and  have  a  weekly  application 
of  leeches  around  the  anus,  she  would  probably  in  time  get  tired  of  the 
treatment,  and  lapse  into  the  very  state  of  apathy  to  which  I  have  alluded. 
There  is  one  class  of  cases  in  dealing  with  which  I  should  especially 
recommend  that  perfect  frankness  be  observed.  It  may  be  represented 
by  a  patient  who  has  been  persuaded  by  husband,  mother,  or  friends, 
contrary  to  her  wishes,  to  submit  to  treatment.  She  utterly  repels  the 
course  to  be  adopted,  is  sure  that  it  will  do  her  no  good,  is  unwilling  to 
fulfil  the  directions  left  her  for  daily  guidance,  but  yields,  under  the  as- 
surance of  her  advisers  that  the  treatment  will  be  free  from  discomfort, 
give  no  pain,  and  will  surely  cure  her  in  a  few  weeks.  The  physician, 
for  the  sake  both  of  his  patient  and  himself,  should  avoid  joining  in  this 
deception.  Stating  the  facts  fully  to  her,  telling  her  of  the  danger  which 
neglect  will  involve,  and  of  her  duty  under  the  circumstances,  he  should 
appeal  to  her  reason,  and  decline  to  take  charge  of  her  case  until  she  really 
desires  his  services. 

Reasons  for  the  Frequency  of  Failure  in  the  Treatment  of  Uterine  Dis- 
eases  That  some  uterine  affections  of  non-malignant  type  are  incurable 

cannot  be  denied;  but  even  putting  these  out  of  consideration,  the  fact  is 
notorious  that  the  local  treatment  of  these  diseases  is  not  as  successful  in 
its  results  as  we  could  wish.  I  now  propose  an  investigation  into  the 
causes  of  this  want  of  success.  It  appears  to  me  that  the  most  apparent 
and  most  constant  of  them  may  thus  be  summed  up: — 

Imperfect  diagnosis ; 

Erroneous  prognosis ; 

Inefficient  or  inappropriate  therapeutics; 

Inattention  to  seiiera!  management. 


62  GENERAL    CONSIDERATIONS    UPON 

Imperfect  Diagnosis — It  is  not  rare  to  meet  with  instances  in  which 
physicians  have,  for  months,  treated  cases  of  uterine  disease  concerning 
the  nature  of  which  they  not  only  did  not  have  a  correct  theory,  hut  had 
no  theory  at  all.  Under  these  circumstances  the  most  general  practice  is 
to  pass,  ahout  once  a  week,  a  solid  stick  of  nitrate  of  silver  up  to  the  os 
internum,  not  to  cure  cervical  endometritis,  for  that  has  never  been  sus- 
pected, but  to  do  the  best  one  can  in  the  way  of  treatment,  when  he  does 
not  know  the  nature  of  the  disease  which  he  treats.  I  have  no  inclination 
to  attribute  this  always  to  any  intentional  laxity  of  morale,  but  rather  to 
indecision  and  aversion  to  creating  a  disagreeable  issue  with  the  patient. 
It  is,  however,  impossible  to  deny  the  fact  that  such  a  course  will  some- 
times be  pursued  by  those  who,  in  the  case  of  a  diseased  eye  or  inflamed 
knee-joint,  would  not  hesitate  to  confess,  with  the  utmost  frankness,  their 
uncertainty  and  need  of  assistance.  With  uterine,  as  well  as  all  other 
diseases,  the  diagnosis  must  be  properly  made  before  treatment  can  prove 
curative ;  and  in  this  field  of  practice,  fully  as  much  as  in  others,  honesty 
and  sincerity  should  guide  the  practitioner.  He  who  practises  deception 
here,  is  surely  no  less  culpable,  although  far  more  likely  to  escape  detec- 
tion, than  the  charlatan  who  makes  it  a  rule  of  life. 

Erroneous  Prognosis Even  if  the  diagnosis  and  treatment  be  correct, 

an  erroneous  prognosis  as  to  time  of  cure  may  so  sap  the  confidence  of  the 
patient  as  to  send  her  to  other  counsel.  And  now  she  may  run  the  gaunt- 
let of  theories  and  therapeutics.  Her  first  attendant  having  recognized 
endometritis  with  resulting  displacement,  the  second  may  treat  the  dis- 
placement alone,  as  the  origin  of  her  symptoms.  Passing  into  the  hands 
of  a  third,  she  may  be  told  that  to  check  her  profuse  leucorrhoea  would  be 
to  cure  her  disease,  which  the  fourth  might  contradict,  with  the  assertion 
that  the  uterine  disorder  was  only  a  complication  of  ovaritis,  which  was 
the  fountain  of  all  her  difficulties. 

Inefficient  or  Inappropriate  Therapeutics  may  cause  failure  in  cure  even 
when  a  proper  diagnosis  and  prognosis  have  been  made.  At  times  a  course 
of  local  alteratives  may  be  persevered  in  when  the  disease  demands  more 
general  treatment.  At  others  it  is  necessary  to  extend  treatment  into  the 
cavity  of  the  body,  and  not  of  the  neck  alone ;  and  at  others  still,  to  per- 
form a  trifling  surgical  operation  to  remove  a  difficulty  which,  unless 
removed,  may  keep  up  the  disease  indefinitely. 

The  best  results  in  the  management  of  these  affections  will  not  follow  a 
direct  resort  to  treatment  of  the  most  prominent  existing  disease,  but  will 
very  often  be  obtained  by  removal  of  its  cause,  or  the  alleviation  of  its 
complications.  Let  me  make  my  meaning  clear  by  some  examples.  The 
physician  examines  and  finds  endometritis  to  exist  with  its  usual  symp- 
toms, bucorrhcea,  pain,  menstrual  disorders,  etc.  This  affection  may  be 
the  result  of  an  antecedent  displacement.  If  it  be  so,  replacing  and  re- 
taining in  position  the  displaced  organ  should  be  the  first  step  in  treatment, 


UTERINE    PATHOLOGY    AND    TREATMENT.  f>3 

as  it  was  the  first  step  in  diseased  action.  Causa  non  sublata  tollitur  non 
effectus,  is  as  true  as  the  converse  proposition.  Again,  a  patient  has 
menorrhagia  and  prolonged  menstruation,  with  a  long,  contracted  cervix 
uteri.  Obstruction  to  the  ready  escape  of  menstrual  blood  often  so  alters 
the  lining  membrane  of  the  body  of  the  uterus  as  to  create  these  disorders. 
If  the  physician  treat  the  symptom,  he  will  surely  fail  in  curing  it,  while 
success  will  attend  his  efforts  if  he  remove  the  obstruction  which  prevents 
the  uterus  from  emptying  itself. 

So  also  with  the  complications  which  are  excited  by  uterine  disorders. 
A  patient  is  affected  by  cervical  endometritis  that  in  time  produces  hyper- 
plasia, which  by  increasing  uterine  weight  displaces  the  uterus.  That 
organ  lying  upon  the  floor  of  the  pelvis  is  injured  by  locomotion  and 
coition,  its  lower  segment  is  bathed  in  purulent  leucorrhoea,  and  great 
pelvic  pain  annoys  and  harasses  the  patient.  If  the  practitioner  expects 
to  cure  her,  let  him,  at  the  same  time  he  treats  the  primary  disease,  the 
endometritis,  relieve  a  set  of  complications  which,  unless  removed,  will 
cause  repeated  relapses  as  often  as  he  approaches  the  accomplishment  of 
his  end. 

One  more  example  may  be  cited  before  concluding  these  remarks.  A 
displacement  of  the  uterus  exists,  and  the  practitioner  knows  that  it  has 
been  due  to  one  of  two  influences,  either  increase  of  uterine  weight,  or 
loss  of  uterine  support.  Which  was  primary  he  cannot  determine,  for  at 
the  time  of  his  examination  both  exist.  To  effect  a  cure  it  would  be  the 
part  of  wisdom  not  to  limit  treatment  to  one,  but  simultaneously  to  treat 
both  by  giving  artificial  support,  and  diminishing  uterine  weight.  With- 
out being  able  to  say  which  is  the  original  disease  and  which  the  com- 
plication, he  should  endeavor  to  relieve  both  at  the  same  time.  And 
here,  unfortunately,  the  patient  is  liable  to  come  in  contact  with  the 
personal  prejudice  of  her  attendant;  he  does  not  approve  of  pessaries. 
Why?  Because  he  has  seen  them  do  great  damage!  Yet  he  does  ap- 
prove of  splints,  of  the  catheter,  of  anaesthesia,  and  of  opium !  Very  likely 
he  has  not  given  an  hour  to  the  investigation  of  this  important  subject  in 
his  whole  professional  career.  How  often  do  patients  come  to  those  spe- 
cially treating  these  diseases,  after  years  of  treatment  from  such  prejudiced 
practitioners,  with  anteversion,  retroversion,  or  slight  prolapse,  and,  obtain- 
ing immediate  relief,  ask  in  surprise  the  significant  question,  why  was  this 
not  done  long  ago 't 

The  surgery  of  gynecology  is  new,  and  like  every  new  and  decided 
improvement  it  has  been  abused  by  indiscreet  and  frequent  resort  to  it  in 
cases  not  requiring  other  than  medical  treatment.  This  has  aroused  a 
prejudice  against  it  in  the  minds  of  many  excellent  conservative  men. 
Nevertheless  it  must  be  apparent  to  every  progressive  gynecologist  that 
the  future  advances  of  this  department  are  to  depend  in  great  degree  upon 
surgery,  that  the  gynecologist  of  the  future  must  necessarily  possess  sur- 


64  GENERAL    CONSIDERATIONS    UPON 

gical  attainments,  and  that  he  who  ignores  this  patent  fact  will  surely 
prove  unequal  to  the  task  which  he  undertakes.  The  day  is  not  far  dis- 
tant when  a  gynecologist  without  surgical  ability  will  be  as  impossible  as 
an  ophthalmologist  is  to-day,  and  much  evil  results  at  present  from  the 
existence  of  the  contrary  state  of  things.  It  is  impossible  to  estimate  how 
many  thousands,  I  would  even  say  millions,  are  now  and  have  been  for 
years  under  treatment  for  various  uterine  disorders  who  could  in  a  month 
be  restored  to  health  by  trachelorrhaphy  ;  how  many  wearing  pessaries  for 
a  lifetime  for  posterior  and  anterior  displacement  could  in  the  same  time 
be  permanently  relieved  by  perineorrhaphy ;  and  how  many  suffering 
lengthily  from  the  discomforts  reflected  from  anal  fissure  would  be  imme- 
diately relieved  by  stretching  the  sphincter  ani. 

Every  man  is  loath  to  acknowledge  incapacity  to  patients  who  believe 
him  to  be  possessed  of  all  medical  science;  and  in  some  of  these  cases,  for 
years  the  patient  is  allowed  to  bear  suffering,  inconvenience,  and  expense 
by  reason  of  the  vanity  and  incompetency  of  her  physician.  In  other 
cases  the  practitioner  is  not  aware  of  the  facts  which  are  here  stated, 
and  he  errs  without  fault,  for  these  views  are  not  generally  known  and 
accepted.  That  they  will  be,  however,  is  as  sure  as  that  "  truth  is  strong 
and  must  prevail." 

Inattention  to  General  Management  and  Hygiene. — The  statement 
which  we  often  meet  with,  that  the  majority  of  the  cases  of  uterine  dis- 
ease require  no  local  treatment  whatever,  is  a  fallacy,  based  either  upon 
strong  prejudice  against  one  of  the  most  important  modern  improvements 
in  medicine,  or  upon  want  of  experience  in  such  cases.  But  too  much 
stress  cannot  be  laid  upon  the  advantages  to  be  derived  from  constitutional 
treatment  and  the  general  management  of  these  cases.  We  too  often  fail 
to  insist  upon  rest,  cessation  of  marital  intercourse,  quietude  after  applica- 
tions to  the  uterus,  and  other  points,  a  neglect  of  which  may  exert  a  pow- 
erful influence  for  evil,  and  frustrate  the  effects  of  all  that  is  done  by  local 
means. 

Astruc  begins  his  directions  for  treating  uterine  ulcers  by  advising — 

"  To  charge  the  patient  to  abstain  from  all  kinds  of  exercise,  and  to  keep 
constantly  laid  down  on  a  long  seat. 

"  It  is  for  the  same  reason  fit,  in  the  case  of  a  married  woman,  that  she 
should  lie  separately  from  her  husband. 

"They  should  for  the  same  reason  guard  against  all  the  passions  of  the 
mind  that  may  agitate  it,  as  grief,  uneasiness,  and  anger,  etc." 

This  advice,  given  over  a  century  ago,  is  often  neglected  to-day,  and 
too  much  reliance  placed  upon  local  means,  and  upon  them  alone.  Every 
one  who  has  had  experience  in  the  treatment  of  these  disorders  must  have 
been  struck  with  surprise  at  the  wonderful  improvement  exerted  upon 
cases,  which  have  long  resisted  local  means,  by  a  sea-voyage,  a  visit  to  a 
watering-place,  a  course  of  sea-bathing,  or  a  few  months  passed  in   the 


UTERINE    PATHOLOGY    AND    TREATMENT.  65 

country.  Not  only  is  this  improvement  manifest  in  tlte  general  state  of 
the  patient  ;  it  shows  itself*  locally,  also,  and  in  some  cases  complete  re- 
covery may  be  thus  attained.  The  same  fact  is  equally  noticeable  in  old 
ulcers  of  the  leg;  local  means,  the  efficacy  of  which  in  such  cases  no  one 
doubts,  having  failed  in  producing  good  results,  entire  recovery  is  effected 
by  means,  such  as  those  alluded  to,  which  act  upon  the  constitution. 

I  remember  having  had  this  very  decidedly  impressed  upon  my  mind 
by  the  following  case :  I  had  for  months  been  treating  a  delicate  lady  for 
marked  retroversion  with  cervical  endometritis  and  hyperplasia,  the  results 
of  an  old  subinvolution.  Suddenly  her  friends  made  up  their  minds  to 
visit  the  Holy  Land,  and  she  was  eager  to  accompany  them,  and  applied 
to  me,  not  for  permission,  but  assent,  for  she  had  evidently  determined  to 
go  before  consulting  me.  A  great  part  of  the  journey  was  to  be  made  on 
horseback  at  a  very  slow  gait,  and  I  really  feared  that  she  would  be  made 
very  ill  by  it.  To  my  surprise,  however,  she  rapidly  improved,  and  re- 
turned to  this  country  better  than  she  had  been  for  years.  And  yet  upon 
examination  I  found  the  uterus  still  out  of  position,  and  granular  degene- 
ration of  the  cervix  still  existing,  though  much  improved. 

It  should  not  be  forgotten  by  the  gynecologist  that  chronic  local  disease 
is  often  caused  by  a  general  depreciation  of  the  system.  In  some  cases 
the  lungs  undergo  chronic  pneumonic  consolidation,  which  often  goes  on 
to  phthisis  ;  in  others,  chronic  corneitis  or  granular  lids  occur  ;  while,  in 
others  still,  cervical  endometritis  marks  the  altered  constitutional  condi- 
tion. When  such  a  result  takes  place,  the  two  states  continue  to  react 
one  upon  the  other.  The  depraved  system  increases  the  local  disorder  to 
which  it  has  given  rise,  and  the  irritation,  kept  up  by  the  latter,  aggra- 
vates the  degree  of  the  former.  This  being  true,  it  would  evidently  be 
irrational  to  treat  one  of  the  two  existing  pathological  conditions  without 
having  due  regard  to  the  other.  Some  cases  of  endometritis,  however, 
occur  in  women  who  are  apparently  in  good  health,  and  are  usually  the 
consequences  of  parturition  or  abortion.  But  cervical,  and  even  corporeal 
endometritis,  the  latter  of  which  may  go  on  to  granular  degeneration, 
will  generally  be  found  to  have  engrafted  themselves  upon  a  depreciated 
system. 

The  following  case  is  illustrative  of  this  view.  Dr.  Alfred  E.  M.  Purdy 
brought  to  my  office,  for  examination,  a  patient  who  had  two  uteri  and 
two  distinct  vagina?.  As  I  proceeded  to  examine,  he  stated  that  the  right 
uterus  was  affected  by  granular  degeneration.  I  discovered,  however, 
that  both  were  thus  diseased.  Dr.  Purdy  had  not  examined  for  some 
weeks,  and,  during  this  period,  the  general  state  which  had  produced  dis- 
ease in  one  uterus  had  effected  the  same  change  in  the  other.  It  may 
with  justice  be  objected  that  both  may  have  been  produced  by  a  local 
cause.  None  such  could  be  discovered,  the  patient  having  been  exposed 
to  no  local  influences  which-had  not  existed  for  years  previously. 
5 


66  SOME    OF    THE    MOST    IMPORTANT 


CHAPTER  IV. 

GENERAL  CONSIDERATIONS  UPON  SOME  OF  THE  MOST  IMPORTANT 
THERAPEUTIC  RESOURCES  OF  GYNECOLOGY. 

It  is  not  my  intention  to  devote  a  chapter  here  to  the  general  considera- 
tion of  the  ordinary  therapeutical  resources  of  this  department,  but,  as 
some  of  the  most  important  of  these  should  be  especially  considered  and 
described,  I  prefer  to  do  so  here,  rather  than  scatter  them  in  a  desultory 
manner  throughout  the  work  where  some  of  them  might  escape  notice. 

At  the  same  time  that  the  judicious  practitioner  should  avoid  routine, 
he  should  not  allow  himself  to  confound  in  his  mind  the  two  terms  routine 
and  system,  and,  while  no  two  cases  should  be  treated  exactly  alike,  a  gene- 
ral plan  will  apply  with  greater  or  less  exactness  to  many. 

General  system  of  diet  and  exercise  for  restoring  the  depreciated  nerve 
and  blood  state  ordinarily  attendant  upon  the  pelvic  diseases  of  women. 

As  a  rule  these  cases  require  a  general  tonic  plan  of  treatment.  There 
are,  however,  a  few  exceptions  to  the  rule,  such,  for  example,  as  cases  in 
which  the  neurasthenia  and  spancemia  so  universal  as  consequences  have 
not  as  yet  arisen,  because  the  patients  have  not  been  long  enough  exposed 
to  the  pathological  condition. 

The  following  are  the  directions  which  I  give  to  patients  for  a  general 
plan  : — 

1.  While  you  are  under  treatment,  remember  that  a  great  deal  will 
depend  upon  your  cordial  co-operation  and  intelligent  endeavor  to  carry 
out  instructions. 

2.  Eat  fresh  animal  food  three  times  a  day,  and  as  much  other  nutritious 
food,  such  as  bread,  crushed  wheat,  potatoes,  rice,  eggs,  etc.,  as  you  can. 

3.  Between  breakfast  and  the  mid-day  meal,  the  mid-day  and  evening 
meal,  and  upon  retiring  at  night,  drink  a  tumbler  of  milk,  or  a  teacupful 
of  beef  tea,  or  of  mutton  or  chicken  broth. 

4.  Every  morning  upon  rising,  and  every  night  upon  retiring,  take  a 
sponge  bath  of  warm  water  strongly  impregnated  with  table  salt,  about  a 
teacupful  to  an  ordinary  basin  of  water.  Then  rub  thoroughly  and  briskly 
with  a  rough  towel :  the  knitted  tape  towel  is  the  best. 

5.  After  each  bath  exercise  for  ten  minutes  briskly  with  dumb-bells, 
the  rowing  machine,  or  light  calisthenic  rods,  breathing  during  this  time 
freely  and  as  deeply  as  possible. 

C.   Endeavor  to  sleep  for  nine   hours  every  night,  and,  for  one  hour  at 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  07 

mid-day  every  day  remove  the  outer  clothing,  lie  quietly  in  bed,  remain 
entirely  without  occupation,  and  if  possible  sleep. 

7.  Have  an  action  by  the  bowels  once  in  every  twenty-four  hours.  If 
constipation  exists,  take  a  tablespoonful  of  this  prescription  every  morning 
on  waking,  in  a  half  tumbler  of  cold  water — 

ty. — Magnesia1  Sulph.  §iv. 
Ferri  Sulph.  3SS- 
Acidi  Sulph.  Dil.  3ij. 
Acpuse,  §xvj. — M. 

8.  During  menstruation  keep  very  quiet,  and  at  all  times  avoid  violent 
muscular  exertion  and  fatigue. 

9.  Use  every  night  and  morning  a  copious  vaginal  injection  of  very 
warm  water,  by  the  method  explained  to  you. 

10.  Be  sure  that  the  clothing  be  loosely  worn,  and  that  all  weight  of 
skirts  be  carried  upon  the  shoulders  and  not  upon  the  hips. 

It  is  tiresome  for  a  practitioner  seeing  a  large  number  of  new  patients 
daily  to  repeat  these  directions  to  each.  He  is  very  apt  too,  even  if  will- 
ing to  assume  the  labor,  to  forget  some  of  them,  and,  even  if  he  do  not,  the 
patient  is  very  sure  to  do  so.  It  is  therefore  very  useful  to  have  them 
printed  upon  a  slip  of  paper,  so  that  a  copy  may  be  carried  home  for  refer- 
ence and  future  guidance. 

Of  course,  in  addition  to  these,  special  cases  will  require  particular  pre- 
scriptions, and  directions  as  to  use  of  stimulants,  etc.  If  the  patient  is  to 
wear  a  pessary  too,  I  am  in  the  habit  of  giving  another  list  of  directions 
having  special  reference  to  the  management  of  this,  which  will  be  given 
in  connection  with  that  subject. 

Pessaries — Uterine  pessaries  hold  a  prominent  position  among  surgical 
appliances,  as  a  means  of  procuring  palliative  and  curative  results.  Like 
all  other  mechanical  means  which  are  powerful  for  good,  they  are  capable 
of  doing  a  great  deal  of  harm.  AVere  I  asked  at  the  present  moment 
whether  I  believed  that  in  the  aggregate  they  accomplished  more  good  or 
evil,  I  should  be  forced  to  give  a  doubtful  reply,  great  an  advocate  as  I 
am  of  their  use.  Their  injurious  consequences  I  wTould  attribute,  not  to 
the  instruments  themselves,  but  to  the  improper  manner  in  which  they 
are  very  often  used,  and  the  carelessness  with  which  they  are  allowed  to 
remain  in  situ  without  observation.  If  splints  were  applied  to  broken 
bones  and  never  examined  until  union  was  effected,  their  utility  would 
soon  become  doubtful.  Pessaries  should  be  carefully  watched,  for  they 
sometimes  create  cellulitis,  peritonitis,  and  vesico-,  recto-,  and  utero-vaginal 
fistulae.  In  some  cases  they  have  been  known  to  pass  completely  out  of 
the  vagina,  into  the  rectum  or  bladder.  Some  years  ago  a  case  entered 
the  service  of  Prof.  L.  A.  Sayre,  of  the  Bellevue  Hospital  Medical  Col- 
lege, presenting  very  obscure  symptoms  of  uterine  disease.  Examination 
proving  that  some  foreign  substance  existed  in  utero,  Prof.  Sayre  dilated 


68  SOME    OF    THE    MOST    IMPORTANT 

the  cervical  canal,  and  extracted  a  globe  pessary  which  had  migrated 
from  the  vagina  into  the  uterus,  and  been  retained  there  for  a  length  of 
time. 

Whatever  pessary  be  employed,  it  should  sustain  the  displaced  uterus 
without  creating  pain  or  discomfort.  Should  any  such  inconvenience  be 
produced,  it  should  be  at  once  removed,  for  the  most  violent  cellulitis  and 
peritonitis  may  result.  While  a  pessary  is  kept  in  the  vagina,  cleanliness 
should  be  secured  by  daily  vaginal  injections,  and  at  intervals,  not  exceed- 
ing two  months,  it  should  be  removed,  examined,  and  reintroduced. 

One  of  the  difficulties  attending  the  use  of  these  instruments  in  general 
practice,  unquestionably  arises  from  the  fact  that  a  great  deal  of  experi- 
ence is  necessary  before  any  one  can  use  them  with  certainty  of  accom- 
plishing good  results.  But  another  is  due  to  the  practitioner  having  only 
a  small  supply  from  which  to  choose.  He  who  habitually  employs  this 
means  should  have  at  his  disposal  a  large  and  varied  assortment,  and 
should  possess  sufficient  mechanical  ingenuity  to  mould  and  adapt  these  to 
the  special  requirements  of  cases  which  may  present  themselves.  The 
vulcanite  pessary  may  be  given  any  shape  after  being  heated,  and  metallic 
ones  may  be  readily  moulded  by  the  fingers. 

Whether  a  suit  for  malpractice  has  ever  arisen  on  account  of  injury 
done  by  a  pessary,  I  cannot  say,  but  I  can  easily  imagine  such  a  source 
of  litigation.  Every  practitioner  should  bear  in  mind,  that  injury  done 
by  a  pessary  does  not  argue  ignorance  on  the  part  of  its  introducer.  When 
one  removes,  as  every  gynecologist  must  often  do,  a  pessary  from  a  posi- 
tion in  the  pelvis  in  which  it  has  become  imbedded,  and  finds,  as  its  re- 
sult, a  ragged,  ulcerative  tract  existing,  he  is  very  apt  hastily  to  conclude 
that  the  instrument  was  improperly  applied.  This  is  by  no  means  always 
true.  I  have  repeatedly  removed  pessaries  under  these  circumstances, 
which  had  been  introduced  by  the  most  competent  gynecologists.  How 
common  it  is  to  find  a  pessary  which  one  has  carefully  introduced,  turned 
completely  upside  down  at  the  end  of  a  week.  The  migratory  and  evolu- 
tionary performances  of  the  vaginal  pessary  are  truly  wonderful.  These 
facts  being  recognized  and  admitted  by  all,  the  evident  deduction  is  that 
it  is  unjust,  as  it  is  unprofessional,  to  expose  to  a  patient,  at  the  expense 
of  an  absent  colleague,  every  lesion  which  these  difiicult  instruments  have 
created.  To  tell  a  patient  that  the  instrument  she  wears  has  made  a  deep 
ulcer  in  the  vagina,  is  to  tell  her  that  her  attending  physician  has  been 
guilty  of  a  gross  blunder  ;  for  "  ulcer,"  in  the  popular  mind,  means  any- 
thing that  is  frightful  in  the  way  of  lesion,  from  erythema  to  carcinoma. 
And  although  the  statement  is  literally  true,  he  who  makes  it  knows  that 
the  same  accident  has  happened  to  himself  many  times,  that  a  week  of 
rest  will  entirely  efface  it,  and  that  no  real  damage  has  resulted  to  the 
patient  from  its  occurrence.  It  cannot  be  denied  that  even  in  our  day 
there  are  those  in  our  profession  whose  minds  have  not  yet  become  disen- 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  69 

thralled  from  the  prejudice  against  gynecology  which  existed  up  to  a  half 
century  ago.  These  too  often  forget  that  the  observance  of  professional 
ethics  should  rise  superior  to  the  promptings  of  an  illiberal  sentiment,  of 
which  every  day  is  proving  the  injustice  and  fallacy.  It  is  a  matter  not 
of  courtesy,  but  of  professional  honor,  to  protect  the  interests  of  a  brother 
practitioner,  as  far  as  the  patient  is  concerned  ;  much  more  so,  where  the 
question  concerns  his  reputation  with  the  public  upon  whose  esteem  his 
usefulness  depends. 

Some  years  ago  a  case  in  point  occurred  to  me,  which  was  so  instructive 
in  this  connection  that  I  venture  to  detail  it.  A  lady  called  upon  me  for 
treatment  for  anteversion,  after  having  been  for  some  months  under  the 
care  of  an  advertising  charlatan  of  this  country.  Upon  removing  a  very 
coarse  and  clumsy  retroversion  pessary,  I  found  a  deep  and  ragged  ulcer 
which  had  penetrated  by  its  lower  extremity  into  the  tissue  intervening 
between  the  vagina  and  bladder.  It  was  deep,  large,  and  ragged.  The 
temptation  was  very  strong  to  expose  the  user  of  this  instrument,  and  to 
make  the  ulcer  the  text  of  a  discourse  upon  the  employment  of  ignorant 
pretenders  by  the  public,  but  upon  second  thought  I  refrained,  put  the 
patient  upon  appropriate  treatment,  and,  as  she  lived  out  of  town,  directed 
her  to  return  in  three  weeks.  At  the  end  of  that  time  she  came  back, 
and,  as  the  ulcer  had  healed,  and  all  vaginal  irritation  had  disappeared, 
I  inserted  an  anteversion  pessary,  and  sent  the  patient  home,  directing 
her  to  see  me  again  in  a  week,  as  that  proved  to  be  the  earliest  moment 
at  which  it  would  be  practicable.  In  a  week  she  returned,  and  to  my 
mortification  I  found  that  pressure  of  the  uterus  upon  the  pessary  had 
created  a  large  and  ragged  ulcer.  The  only  difference  between  that  created 
by  myself  and  by  the  charlatan  was,  that  mine  was  a  little  the  larger  and 
more  vicious  in  appearance. 

It  is  this  very  danger  which  now  makes  me  so  scrupulous  about  ex- 
amining an  anteversion  pessary  repeatedly  during  the  first  ten  days  of  its 
sojourn  in  the  vagina. 

In  spite  of  all  its  attendant  evils,  the  use  of  the  pessary  is,  as  I  have 
said  before,  one  of  the  most  important  points  in  gynecology,  and  every 
practitioner  of  that  art  should  make  it  a  faithful,  special,  and  constant 
study.  I  confess  that  when  I  am  told,  as  I  sometimes  am  by  physicians, 
that  they  never  use  pessaries,  because  they  are  so  strongly  prejudiced 
against  them,  the  question  always  arises  in  my  mind,  then  how  and  why 
do  you  treat  uterine  diseases  ?  How  pessaries  can  be  dispensed  with  is  to 
me  one  of  the  unfathomable  mysteries  of  gynecological  practice.  And 
why  any  one  should  practise  an  art  and  ignore  a  means  which,  properly 
mastered,  constitutes  one  of  the  most  powerful  and  reliable  of  its  resources, 
is  equally  incomprehensible. 

I  think  it  an  excellent  plan  for  the  physician  who  has  inserted  a  pessary 
to  give  to  the  patient  some  such  written  directions  as  those  which  follow, 


70  SOME    OF    THE    MOST    IMPORTANT 

urging  her,  in  case  of  trouble  from  the  instrument,  to  refer  to  and  closely 
abide  by  them. 

1st.  You  are  wearing  a  pessary.  If  it  give  you  pain,  pass  your  finger 
into  the  ring  which  you  will  feel  and  draw  it  away.  Do  not  mind  a  little 
discomfort  in  doing  this,  but  do  it  without  fail. 

2d.  If  after  this  you  suffer  pain,  go  to  bed  and  send  for  a  physician. 

3d.  Every  night  and  morning  put  one  or  two  gallons  of  hot  water  in  a 
tub,  sit  over  this,  and  with  the  "  Davidson's  syringe"  syringe  out  the 
vagina  for  five  minutes.  The  water  should  be  as  warm  as  you  can  com- 
fortably bear  it. 

4th.  Wear  your  clothing  as  loosely  as  possible,  using"  skirt  supporters," 
and  not  wearing  tight  corsets. 

5th.  Keep  the  bowels  regular,  securing  one  action  every  day. 

6th.  Avoid,  as  much  as  possible,  going  up  stairs,  lifting  heavy  weights, 
using  the  sewing  machine,  and  riding  in  a  rough  vehicle. 

7th.  Lie  down  for  an  hour  at  midday  every  day,  and  keep  very  quiet  at 
menstrual  periods. 

8th.  Remember  that  attention  to  these  directions  will  have  an  important 
influence  on  your  recovery. 

Precautions  to  be  uniformly  observed  in  operations  upon  the  sexual 
organs  of  the  female,  for  prevention  of  septiccemia  and  pi/cemia. 

One  of  the  greatest  achievements  of  modern  pathology  has  been  the 
discovery  of  the  agency  of  certain  families  of  lowly  organized  nomads 
and  micrococci  in  the  production  of  diseased  states  which  the  humoral 
pathology  of  the  olden  time  had  traced  to  the  blood.  Although  the  sub- 
ject, born  only  twenty  years  ago,  is  still  in  its  infancy,  a  great  deal  has 
already  been  accomplished  in  reference  to  it,  and  it  is  not  too  much  to 
hope  that  the  path  has  been  struck  which  is  destined  to  lead  to  an  eluci- 
dation of  "contagion," — "the  pestilence,"  as  Holy  "Writ  expresses  it, 
"that  walketh  in  darkness."  Those  who  were  chiefly  instrumental  in 
establishing  our  knowledge  upon  this  point  are  Virchow,  Rindfleisch, 
Recklinghausen,  Hueter,  Vogt,  and  Klebs. 

During  the  last  ten  years  the  subject  has  received  great  attention,  and 
diphtheria,  septicaemia,  pyaemia,  malignant  pustule,  scarlet  fever,  variola, 
and,  according  to  Letzerich,  whooping-cough  are  classed  among  diseases 
due  to  fungi  or  micrococci.  The  only  ones  of  the  affections  which  spe- 
cially concern  us  are  pyaemia  and  septicaemia,  which,  although  many  dis- 
sent from  the  view,  it  is  very  generally  agreed  originate  in  the  introduction 
into  the  blood  of  bacteria  of  the  rod  and  globular  variety.  These,  being 
absorbed  by  bloodvessels  and  lymphatics  upon  a  wounded  surface,  are  dis- 
tributed through  the  system,  causing  decomposition  of  the  blood,  and 
resulting  in  septicaemia,  pyaemia,  septic  emboli,  thromboses,  and  localized 
inflammations. 

Upon    theoretical    grounds  a  pathological   discovery   of   this    peculiar 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  71 

kind  would  have  been  naturally  expected  to  emanate  from  the  patholo- 
gical laboratories  of  Germany.  But  for  Great  Britain  was  reserved  the 
honor  of  utilizing  the  seductive  theory.  Lister,  of  Scotland,  basing  his 
researches  upon  the  facts  just  mentioned,  endeavored  with  wonderful  suc- 
cess to  prevent  the  entrance  of  bacteria  into  the  blood  during  and  just 
after  any  suddenly  occurring  solution  of  continuity.  These  products  of 
the  vegetable  world  may  be  encountered  anywhere,  but  are  especially  met 
with  in  hospitals  and  other  places  where  the  sick  are  crowded  together ; 
for  example,  upon  the  walls,  floating  in  the  air,  upon  the  hands  of  sur- 
geons or  assistants,  upon  instruments,  ligatures,  sutures,  dressings,  band- 
ages, and  sponges. 

To  be  secure  then  against  the  entrance  of  bacteria  into  the  open  vessels 
of  wounds,  the  greatest  care  must  be  exercised.  Prof.  Zweifel,1  of  I>lan- 
gen,  once  performed  an  operation  for  closure  of  a  vesico-vaginal  fistula, 
and  lost  his  patient  from  septicaemia  on  the  twelfth  day.  Antiseptic 
measures  had  been  carefully  observed,  and  he  was  at  a  loss  to  account  for 
the  accident,  until  he  examined  by  the  microscope  the  catgut  used  for 
suture.  This,  although  kept  in  carbolized  oil,  he  found  filled  with  bac- 
teria, which  he  thought  were  thus  introduced  into  the  economy. 

Not  only  are  instruments,  needles,  thread,  etc.,  to  be  carefully  disin- 
fected, the  room  in  which  an  operation  is  performed  should  always  be 
carefully  cleansed  and  disinfected  likewise.  The  experiments  of  Pasteur3 
prove  that  the  germs  of  such  organisms  as  micrococci,  bacteria,  etc.,  are 
everywhere  present  in  the  air,  especially  in  that  of  hospitals,  which  like- 
wise contains  floating  in  it  pus  globules  and  spores  of  epiphytic  parasites 
which  emanate  from  diseased  organisms.  In  1865  Broca  had  the  walls  of 
St.  Antonio  Hospital  sponged,  and  in  the  liquid  expressed  from  the 
sponges  he  detected  pus  globules.  In  1861  Eiselt,  of  Prague,  placing  an 
instrument  analogous  to  Pouchet's  aeroscope  between  two  beds  of  a  ward 
occupied  by  thirty-three  children  suffering  from  purulent  ophthalmia,  dis- 
tinctly detected  the  presence  of  pus  globules  floating  in  the  air.  Nepveu, 
of  Paris,  had  one  square  metre  of  wall  in  the  surgical  ward  of  La  Pitie 
sponged,  and  discovered  in  the  liquid  expressed  micrococci  in  large 
amounts,  several  micro-bacteria,  epithelial  cells  in  small  number,  several 
pus  globules,  several  red  globules,  and,  lastly,  irregular  blackish  masses 
and  ovoid  bodies  whose  nature  was  unknown. 

It  is  against  the  agency  of  these  poisons  that  cleanliness  as  strict  as  it 
is  possible  to  make  it,  circulation  of  pure  air  in  the  chamber  of  the  patient, 
and  all  the  antiseptic  measures  so  fortunately  introduced  by  Lister  seem 
to  guard. 

In  boracic,  sulphurous,  and  carbolic  acids,  and  other  chemical  com- 

•  Centralblatt  fur  Chir.,  No.  XII.  1879. 

2  Revue  Med.  de  l'Est,  Revue  de  Therap.,  No.  23,  1874. 


72  SOME    OF    THE    MOST    IMPORTANT 

|>ounds,  have  been  found  septicide  agents  capable  of  destroying  these  lowly 
organized  germs.  Of  these  Lister  has  found  carbolic  acid  to  be  the  best 
up  to  the  present  time;  and,  by  thoroughly  cleansing  instruments,  hands, 
dressings,  and  sponges,  and  by  saturating  not  only  them,  but  the  atmos- 
phere coming  in  contact  with  the  abraded  surfaces,  with  carbolized  water, 
he  has  so  completely  closed  every  avenue  of  bacterial  approach  that  sepsis 
and  its  consequences  have  been  to  a  great  extent  prevented. 

Should  the  theories  of  Lister  prove  to  be  true,  and  they  certainly  pro- 
mise so  to  do,  surely  the  fact  will  not  be  disputed  that  no  one  of  his  pre- 
decessors has  accomplished  more  brilliant  results  for  practical  surgery  than 
he.  Unless  we  are  greatly  in  error,  thousands  of  lives  have  already  been 
saved  by  his  efforts,  and  who  can  estimate  what  the  future  will  bring 
forth?  His  methods  may  all  be  changed,  and  the  use  of  the  spray  may 
pass  away,  but  the  grand  principle,  the  pivotal  truth  which  he  has  given 
us,  will  probably  live  forever. 

Let  the  gynecological  surgeon  keep  constantly  before  his  mind  the  fact 
that  uncleanliness  goes  hand  in  hand  with  bad,  and  cleanliness  with  good 
surgery.  Simple  as  this  agency  seems,  it  is  the  sole  one  upon  which  rests 
the  greatest  advance  of  modern  surgery.  Emmet  says,  truly,  "  many  a 
woman's  death  warrant  is  carried  under  the  nails  of  her  surgeon."  Many 
years  ago  a  humorous  medical  writer,  half  in  jest,  elevated  the  tongue- 
scraper  to  a  place  of  dignity  in  the  treatment  of  dyspepsia.  The  nail- 
brush, in  serious  earnest,  deserves  such  a  position  as  a  prophylactic  of 
lymphangitis  and  septicaemia. 

It  is  a  well-authenticated  fact  that  the  scratch  of  the  lion,  tiger,  et  id 
genus  omne,  even  when  very  insignificant,  proves  dangerous  through  ery- 
sipelas and  lymphangitis,  which  are  very  apt  to  ensue.  The  claws  of 
these  predatory  carnivore  are  constantly  charged  with  decaying  animal 
matters,  the  accumulation  of  years,  and  they  infect  the  wounds  which  they 
make  as  the  lancet  of  the  vaccinator,  the  poisoned  arrow  of  the  Indian,  or 
the  nails  of  the  uncleanly  surgeon  do. 

Nowhere  is  cleanliness  of  such  primary  importance  as  in  obstetrics  and 
surgery.  In  every  exploration,  every,  even  the  most  trivial,  operation  in 
gynecology  and  obstetrics,  Lister's  methods,  except  the  spray,  should  be 
strictly  observed,  and  in  all  grave  operations  the  spray  too  should  be  em- 
ployed. 

The  following  rules  should  always  be  observed  in  operating  on  the 
female  genitalia : — 

1st.  Before  and  after  every  operation  wash  all  instruments  in  very  hot. 
carbolized  water,  and  during  every  operation  keep  all  instruments  immersed 
in  carbolized  water.  This  should  especially  be  observed  in  regard  to 
needles  and  sutures. 

2d.  In  all  laparotomy  operations  pursue  Lister's  antiseptic  method  fully. 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  73 

3d.  Where  the  spray  is  not  employed,  always  bathe  denuded  surfaces, 
both  before  and  after  apposition  by  suture,  with  carbolized  water. 

4th.  Always  destroy  sponges  used  in  an  operation  which  admits  of  the 
possibility  of  these  being  contaminated  by  septic  fluids,  and  when  they  are 
employed  a  second  time  always  have  them  immersed  previously  in  boiling 
carbolized  water. 

5th.  After  all  operations  upon  the  uterus  bathe  or  spray  the  vaginal  por- 
tion of  the  organ  with  carbolized  water,  and  tampon  lightly  lor  twenty- 
four  hours  with  antiseptic  cotton.  This  being  removed,  syringe  the  vagina 
with  carbolized  water  at  short  intervals. 

6th.  After  all  operations  on  the  pelvic  organs  syringe  the  vagina  with 
carbolized  water  as  often  as  once  in  every  eight  hours. 

7th.  After  all  operations  quiet  pain  and  nervous  excitement  by  opium. 

8th.  Before  all  grave  operations  give  a  full  dose  of  quinine,  ten  to 
fifteen  grains. 

9th.  Before  every  operation  let  the  operator  and  his  assistants  cleanse 
and  disinfect  their  hands  as  if  they  felt  sure  that  septic  material  attached 
to  them. 

10th.  Avoid  even  trivial  operations,  unless  good  reason  for  doing  other- 
wise exist,  for  a  few  days  before  and  after  menstruation. 

That  a  strict  observance  of  all  these  precautionary  rules  will  uniformly 
prevent  the  development  of  lymphangitis,  septicemia,  and  peritonitis,  I 
neither  believe  nor  maintain.  That  it  will  do  a  great  deal  towards  dimin- 
ishing the  frequency  of  these  accidents,  I  am  entirely  convinced  by  ob- 
servation and  experience.  That  they  are  of  value  I  feel  sure.  That  they 
are  not  essential  is  fully  proved  by  the  successful  results,  which  we  daily 
see  around  us,  of  operations  practised  with  entire  disregard  of  every  one 
of  them. 

Even  in  ordinary  examinations  of  the  uterus  the  antiseptic  idea  should 
always  be  kept  in  mind.  The  plan  which  I  follow,  therefore,  is  this  :  Every 
day  my  office  nurse  pours  boiling  water  upon  all  the  instruments  ordinarily 
employed,  such  as  speculum,  probe,  sound,  tenaculum,  depressor,  etc., 
washes  them  carefully  with  soap,  and  rubs  them  bright  with  a  substance 
called  electro-silicon.  They  are  then  kept  immersed  in  carbolized  water 
during  examinations.  After  every  examination  the  instruments  used  are 
again  washed  with  soap,  rapidly  rubbed  bright,  and  immersed  in  a  fresh 
supply  of  carbolized  water.  After  every  examination  the  examiner's  hands 
are  carefully  washed  with  soap  in  very  warm  water,  the  nail-brush  freely 
used,  and  just  before  another  examination  they  are  rinsed  in  the  car- 
bolized water  in  which  the  instruments  are  brought  in.  The  fingers  and 
all  instruments  introduced  either  into  the  vagina  or  uterus  are  lubricated 
with  carbolized  vaseline,  carbolic  soap,  or  soft  soap  thoroughly  carbolized. 
In  these  examinations  absorbent  cotton,  held  in  a  pair  of  dressing  forceps 


74  SOME    OF    THE    MOST    IMPORTANT 

like  those  shown  in  Fig.  2,  should  he  made  to  replace  sponge,  which  is  so 
much  more  likely  to  carry  contagion  from  one  patient  to  another. 

Fig.  2. 


Thomas's  dressing  forceps. 

Tliat  patients  are  at  times  injured  by  want  of  proper  hygienic  precau- 
tions on  the  part  of  gynecologists,  I  feel  assured  hy  personal  observation. 
That  the  contamination  of  women  through  their  criminal  ignorance  or 
carelessness  is  not  much  more  frequent,  is  a  matter  of  unceasing  amaze- 
ment to  me.  Every  gynecologist  should  feel  two  things  very  sincerely 
with  reference  to  his  daily  system  of  examinations.  1st.  That  he  would 
be  willing  to  have  his  own  female  relatives  exposed  to  all  the  risks  of 
contagion  to  which  he  exposes  his  patients ;  and  2d.  That  he  would  at 
any  time  willingly  submit  his  methods  to  the  critical  investigation  of  a 
jury  of  his  peers  as  far  as  concerns  cleanliness  and  hygiene. 

After  operations  where  it  becomes  necessary  to  have  the  bladder 
evacuated  by  the  catheter,  the  precaution  should  always  be  observed  of 
dipping  the  catheter  in  carbolized  water  and  smearing  it  with  carbolized 
oil  or  vaseline  before  its  introduction.  A  neglect  of  this  often  results  in 
prolonged  vesical  trouble  which  might  readily  have  been  avoided. 

Vaginal  Injections There  is  no  agent  in  the  treatment  of  diseases  of 

the  pelvic  viscera  which  possesses  greater  value  than  this,  and  yet  none 
which  lias  been  used  from  time  immemorial  in  a  more  unsystematic  and 
desultory  manner.  Until  the  appearance  of  Scanzoni's  work,  now  over 
twenty  years  ago,  very  small  amounts  of  fluid  were  used,  not  nearly  enough 
to  wash  out  the  vaginal  canal  thoroughly,  and  the  little  piston  syringe 
employed  for  the  purpose,  and  holding  only  about  an  ounce,  was  utterly  in- 
sufficient. Scanzoni  taught  us  the  important  lesson  that  copious  vaginal 
injections  should  always  be  employed  where  this  method  was  resorted  to, 
and  gave  us  several  very  excellent  plans  for  using  them.  This  was  an  im- 
portant step  in  advance.  Since  that  time  P^mmet  has  done  a  great  deal 
to  systematize  the  matter,  and  introduced  a  method  which  I  shall  lay  before 
the  reader.     His  method  is  based  upon  the  following  deductions  : — 

1st.  That  no  patient  can  use  vaginal  injections  efficiently  herself,  but 
must  have  them  administered  by  another. 

2d.  That  for  them  to  be  effectual  the  patient  must  lie  upon  the  back 
with  the  hips  elevated. 

3d.  That  a  copious  flow  over  the  vaginal  surface  of  water  varying  in 
temperature  from  100°  F.  to  110°  F.  is  most  appropriate  for  all  cases  in 
which  congestion  exists. 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  75 

4th.  That  cold  water  thus  employed  is  hurtful  by  causing  first  vascular 
contraction  and  afterwards  dilatation,  while  hot  water  produces  first  ex- 
pansion and  then  contraction. 

"  The  injection,"  says  he,  "  can  be  better  given  to  the  patient  after  she 
is  undressed  for  the  night  and  in  bed.  She  should  be  placed  near  the  edge 
of  the  bed  with  the  hips  elevated  as  much  as  possible  by  the  bedpan,  and 
a  small  pillow  under  her  back,  the  lower  limbs  being  flexed.  Her  body 
must  he  covered,  to  protect  her  from  cold,  and  her  position  made  perfectly 
comfortable  ;  whenever  the  bed  is  a  soft  one,  for  the  purpose  of  keeping  the 
hips  elevated,  a  broad  board  should  be  placed  under  the  pan  to  prevent  it 
from  sinking  into  the  bed  from  the  weight  of  the  patient.  The  vessel  of 
hot  water  is  placed  on  a  chair  by  the  bedside,  and  the  nurse  passes  the 
nozzle  of  the  syringe  into  the  vagina,  over  the  perineum,  directing  it  along 
the  recto-vaginal  wall  until  it  has  reached  the  posterior  cul-de-sac.  The 
water  must  be  thrown  in,  at  first,  very  carefully,  until  the  vagina  has  be- 
come distended." 

In  hospital  practice  there  is  no  method  as  good  as  this  carried  out  in  all 
its  details,  but  in  private  practice  every  one  must  see  the  difficulties  which 
will  attend  it.  Dr.  Emmet  says,  that  "few  women  are  so  situated  as  to 
be  unable  to  get  some  one  to  administer  the  injections  properly."  I  should 
alter  the  sentence,  making  it  read  "few  women  are  so  situated  as  to  be 
able ;"  for  a  lady  does  not  like  to  call  upon  a  servant  to  perform  so  deli- 
cate a  task  for  her,  nor  is  she  willing  either  to  impose  it  upon  an  equal 
or  to  bear  the  heavy  expense  of  having  a  professional  nurse  visit  her  daily. 
Under  these  circumstances  I  employ  the  following  plan.  The  patient 
places  a  pillow  upon  the  edge  of  her  bed  and  an  empty  tub  upon  the  floor 
under  it.  She  then  covers  the  pillow  by  a  piece  of  India-rubber  cloth 
which  drapes  into  the  tub.  Then,  putting  two  chairs  one  on  each  side  and 
a  little  in  front  of  the  tub,  she  places  a  small  table  in  front  of  these,  and 
upon  this  another  chair.  Upon  the  chair  which  stands  on  the  table  a  tub 
containing  about  two  gallons  of  hot  water  is  now  put,  near  the  bottom  of 
which  has  been  inserted  a  spigot  to  which  a  long  rubber  tube  is  affixed, 
which  ends  in  a  vaginal  nozzle.  The  patient  now  lies  upon  the  bed,  the 
pelvis  elevated  by  the  pillow,  places  her  feet  upon  the  chair,  covers  her 
limbs  with  a  shawl  or  blanket,  touches  the  spring,  an  ordinary  clothes-pin 
makes  a  good  one,  which  controls  the  flow,  and  the  water  bathes  the 
vagina,  and  running  out  is  conducted  by  the  India-rubber  cloth  into  the  tub. 

Here  the  only  articles  purchased  are  the  tub  with  the  spigot  and  tube 
attached,  and  a  yard  of  India-rubber  cloth,  which  are  inexpensive.  The 
patient  will  have  everything  else  in  her  chamber,  and  very  little  trouble 
attaches  to  the  method,  which  is  certainly  an  efficient  one. 

"While  I  admit  the  great  value  of  Emmet's  method,  I  do  not  by  any 
means  admit  his  postulate  that  "  not  the  slightest  advantage  is  received  from 
them  (vaginal  injections)  when  administered  with  the  patient  in  the  upright 


76 


SOME    OF    THE    MOST    IMPORTANT 


posture,  or,  as  is  the  usual  method,  while  seated  over  a  bidet."  Thus 
administered  they  are  less  effectual  than  in  the  method  described,  but  still 
they  do  a  great  deal  of  good.  While  a  patient  is  travelling,  or  in  cases 
where  injections  are  required  only  for  cleanliness,  they  may  be  relied  upon 
to  do  very  good  work,  and  I,  therefore,  describe  the  method  of  employing 
them.  Placing  in  a  tub  from  one  to  two  gallons  of  water,  at  as  high  a 
temperature  as  proves  comfortable  to  the  patient,  she  may  sit  over  it  upon 
a  board  placed  across  it,  or  upon  a  stool  placed  in 
Fig.  3.  it,  and  inject  the  water  by  means  of  a  syringe.     The 

most  convenient  syringes  for  the  purpose  are  the 
Essex  and  Davidson's.  Both  of  these  are  provided 
with  a  stem  about  five  inches  long,  which  being  in- 
troduced into  the  vagina  and  carried  up  so  as  to 
Davidson's  syringe.  touch  the  cervix,  throws,  when  the  ball  of  the  in- 
strument is  compressed  by  the  disengaged  hand  of  the 
patient,  a  steady  stream  against  it.  By  this  means  a  stream  of  warm  water 
is  made  to  pour  over  the  cervix  for  from  twenty  to  thirty  minutes,  accord- 
ing to  the  amount  of  fatigue  which  the  use  of  the  instrument  causes  the 
patient. 

Warm  water  is  the  best,  as  it  is  the  simplest,  most  attainable,  and 
cleanest  of  all  the  emollients  which  can  be  used  for  this  purpose.  But  it 
may  easily  be  medicated  by  the  addition  of  laudanum,  half  an  ounce  to 
the  gallon  ;  infusions  of  linseed,  poppies,  hops,  bran,  slippery  elm,  starch, 
hyoscyamus,  conium,  or  farina  ;  or  by  the  addition  of  glycerine,  one  ounce 
to  the  gallon,  lime-water  or  tar-water,  both  of  which  last  are  often  very 
soothing  to  vaginitis  that  may  exist  as  a  complication. 

A  few  words  are  essential  in  reference  to  the  nozzle  which  should  be 
used  in  giving  these  injections.     No  amount  of  care  will  prevent  the  in- 


Fig.  4. 


Vaginal  syringe  nozzle,  with  reverse  current. 


jection  of  fluid  into  the  uterine  cavity  unless  the  nozzle  be  properly  con- 
structed. Sometimes  where  the  cervix  is  lacerated  or  the  cervical  canal 
dilated  the  patient  will  carry  the  instrument  directly  into  the  os  externum 
and  project  a  large  amount  of  fluid  into  the  uterus  Such  an  accident  is 
followed  by  violent  uterine  contraction,  and  the  probable  passage  of  a  por- 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  77 

tion  of  the  liquid  into  and  perhaps  through  the  Fallopian  tubes,  and  this 
often  results  in  a  degree  of  pain  which  almost  causes  collapse,  and  some- 
times even  in  pelvic  peritonitis.  This  accident  can  always  be  prevented 
by  having  the  nozzle  of  the  syringe  made  with  a  reverse  current  as  repre- 
sented in  the  diagram.  I  have  for  many  years  employed  those  made  of 
hard  rubber,  and  it  seems  to  me  that  in  view  of  the  fact  that  serious  ac- 
cidents sometimes  follow  the  use  of  nozzles  with  direct  jet,  the  precaution 
of  reversing  the  current  should  always  be  observed  by  instrument  makers. 

The  Tampon Had  Sims's  method  of  uterine  examination  done  nothing 

else  than  lead  to  the  proper  method  of  using  the  vaginal  tampon,  it  would 
have  done  by  that  alone  a  vast  deal  of  good.  Before  its  introduction  the  use 
of  the  tampon  was  a  painful,  uncertain,  and  inefficient  hemostatic  method. 
Since  the  use  of  Sims's  speculum  it  has  become  an  easy,  painless,  scientific, 
and  most  effectual  method  for  preventing  and  checking  hemorrhage  from 
the  non-pregnant  uterus.  The  operator  in  gynecology  who  does  not  under- 
stand the  modern  method  of  tamponing  the  vagina,  and  who  still  relies 
upon  the  introduction  by  the  fingers  of  a  "  kite-tail  tampon,"  a  silk  hand- 
kerchief, pieces  of  cotton,  or  this  combined  with  sponge,  etc.,  surely  does 
great  injustice,  both  to  his  patient  and  himself,  and  courts  hemorrhage — 
an  evil  which  might  easily  be  avoided. 

In  speaking  of  the  vaginal  tampon  a  recent  writer1  says  :  "  It  is  a  barbar- 
ous, slovenly,  unscientific  proceeding,  and  is  generally  based  upon  incompe- 
tence and  instigated  by  terror.  If  hemorrhage  be  issuing  from  a  closed 
os,  it  may  be  plugged  with  a  sponge  tent,  in  order  that  the  source  may  be 
afterward  reached.  But  if  the  cause  of  the  hemorrhage  be  known  and  be 
irremovable,  the  treatment  should  be  to  inject  the  uterus  with  acetic  acid, 
or  even  with  some  salt  of  iron,  though  the  latter  is  a  proceeding  accom- 
panied by  terrible  risks."  I  quote  this  to  say  how  entirely  I  dissent  from 
it.  The  tampon  properly  applied  is  not  only  a  simple,  cleanly,  and  pain- 
less procedure ;  it  is  safer,  more  efficient,  and  more  scientific  than  the  alter- 
natives here  suggested. 

The  patient  being  placed  upon  a  table  upon  the  left  side,  Sims's  specu- 
lum is  introduced  and  held  by  an  assistant,  while  with  sponges  or  rolls  of 
cotton  the  surgeon  removes  from  the  vagina  all  mucus  and  blood  clots 
which  may  exist  there.  Upon  a  plate  near  him  have  been  placed  a  num- 
ber of  thick  disks  of  carbolized  cotton,  some  soaked  in  solution  of  per- 
sulphate of  iron  one-third  to  water  two-thirds,  or  in  a  saturated  solution 
of  alum  or  copper,  and  others  simply  saturated  with  water.  All  superflu- 
ous fluid  has  been  squeezed  out  by  pressing  these  disks  between  cloths. 
Taking  up  in  the  dressing  forceps  one  of  the  disks  which  has  been  satu- 
rated with  an  astringent,  the  surgeon  packs  this  behind  the  neck  of  the 
uterus,  then  alongside  of  this  he  places  another,  holding  the  first  one  well 

1  Lawson  Tait,  Diseases  of  Women,  1877. 


78  SOME    OF    THE    MOST    IMPORTANT 

in  place,  meantime,  by  a  rod  of  whalebone,  or  other  similar  substance, 
until  the  second  is  placed.  In  this  way  piece  after  piece  is  packed  away 
until  a  collar  is  placed  around  the  neck  of  the  uterus  which  extends  to  a 
level  with  the  os  externum.  Then  this  part  is  covered  with  more  astrin- 
gent cotton,  which  is  packed  into  place  and  held  there  by  pressure  from  a 
rod,  and  simply  wet  cotton  is  packed  upon  it  until  the  vagina  has  been 
filled  to  within  an  inch  of  the  vulva,  when  a  piece  of  soft  dry  cotton  is 
made  to  hold  the  more  efficient  upper  tampon  in  position.  The  lower 
portion  is  now  carefully  pushed  away  from  the  urethra,  and,  a  dry  soft 
towel  being  laid  over  the  vulva,  a  T  bandage  is  applied. 

Such  a  tampon  is  a  safe  hemostatic  agent.  After  operations  upon 
vagina,  vulva,  or  cervix,  it  proves  a  most  certain  preventive  of  hemor- 
rhage. As  a  means  for  checking  hemorrhage,  already  fully  established,  it 
has  no  equal  in  value  in  gynecological  surgery. 

When  it  is  necessary  to  remove  this  tampon,  which  maybe  left  in  posi- 
tion for  twenty-four  or  even  thirty-six  hours,  two  methods  present  them- 
selves. First,  the  speculum  may  be  gradually  introduced,  and  each  piece 
of  cotton  as  it  becomes  visible  be  caught  by  a  tenaculum  and  pulled  out 
until  the  last  piece  is  removed.  Second,  the  position  of  the  patient  being 
unaltered,  one  finger  is  passed  up  until  the  cotton  is  touched  ;  then  the 
screw,  represented  in  Fig.  5,  is  slipped  along  it,  and  by  a  few  turns  im- 
bedded in  the  mass.     Traction  is  then  made  and  a  portion  of  the  tampon 

Fig.  5. 


Sims's  screw  for  removing  a  tampon. 

is  removed.  After  this  another  piece  is  caught  and  drawn  away  until  the 
vagina  is  emptied.  In  cases  in  which  it  is  desirable  not  to  move  the 
patient  for  fear  of  fatiguing  her,  and  where  no  second  tampon  is  to  be 
applied,  this  ingenious  instrument  answers  an  excellent  purpose. 

Means  for  controlling  the  temperature  after  operations,  and  during 
pathological  conditions  developing  in  gynecology. 

The  most  careful  observation  and  a  large  clinical  experience  have  led 
me  to  the  conclusion  that  one  of  the  most  momentous  problems  in  thera- 
peutics consists  in  keeping  the  animal  heat  within  proper  bounds.  In  my 
opinion  one  of  the  most  important  impressions  which  should  gain  firm 
foothold  in  the  mind  of  every  practitioner  is  this:  Prolonged  high  tem- 
perature kills.  In  many  diseases,  such,  for  example,  as  septicaemia,  typhus 
and  typhoid  fever,  peritonitis,  sunstroke,  scarlet  fever,  etc.,  it  is  com- 
monly  the  chief  and  most  immediate  factor  by  which  a  fatal  issue  is  pro- 
duced ;  in  many  others  it  is  a  prominent,  though  not  the  chief,  agent 
which  exhausts  the  vital  forces;  while  in  others  still,  such  as  chronic  brain 


THERAPEUTIC    RESOURCES    OF    GYNECOLOGY.  79 

diseases,  dysentery,  cancer,  chronic  cardiac  diseases,  etc.,  it  is  no  factor 
at  all. 

If  for  a  week  a  very  high  temperature  has  been  allowed  to  continue  in 
any  case,  death  will  very  likely  result  from  this  continuance  at  a  later 
period  of  the  disorder,  even  if  at  the  end  of  that  time  it  be  lowered  and 
kept  within  proper  bounds.  The  vitality  of  the  blood  has  been  impaired  ; 
the  muscular  and  nerve  tissues  supplied  by  the  depreciated  fluid  are  altered, 
and  the  structure  of  important  organs  changed  in  character  ;  and  these 
unfortunate  occurrences  lead  on  to  death.  In  a  lengthy  case  of  typhoid 
fever  the  temperature  being  allowed  to  remain  for  three  or  four  weeks  at 
or  near  104°,  it  becomes  lower  by  the  self-limitation  of  the  disease.  At 
that  time  pneumonia  or  some  other  complication  develops,  and  the  patient 
dies.  Under  these  circumstances  death  is  regarded  as  having  been  due 
to  an  unavoidable  complication  ;  but,  if  the  blood  state  had  not  been 
steadily  depreciated  by  the  antecedent  month  of  high  temperature,  the 
complication  would  very  likely  not  have  occurred. 

A  child  passes  through  the  first  eight  or  ten  days  of  scarlet  fever  with 
a  temperature  at  or  near  105°,  and  then  succumbs  to  cerebral  exhaustion, 
secondary  meningitis,  or  pneumonia.  Had  the  pathological  conditions 
created  by  ten  days  of  a  temperature  of  105°  not  been  allowed  to  occur, 
these  secondary  manifestations  might  have  been  avoided.  To  elicit  all 
the  beneficent  results  which  control  of  temperature  can  produce,  such 
control  must  be  exercised  :  (a)  throughout  the  course  of  the  disease  from 
its  beginning  to  its  end ;  (b)  by  means  which  do  not  disorder  digestion 
or  exhaust  the  strength;  (c)  by  means  which  are  certain,  systematic,  and 
always  attainable. 

These  remarks  apply  to  the  whole  field  of  medicine,  but  in  no  depart- 
ment of  it  have  they  greater  force  than  in  that  which  especially  engages  our 
attention.  The  diseases  which  the  gynecologist  most  dreads,  to  which  the 
largest  number  of  his  patients  succumb,  and  consequently  with  which  in 
his  daily  labors  he  has  most  frequently  to  cope  are  two,  which  destroy  life 
in  great  degree  by  exhausting  the  vital  forces  by  high  temperature — 
peritonitis  and  septicaemia.  Give  him  control  over  these  and  the  most 
melancholy  part  of  his  daily  functions  would  be  obliterated!  Arm  him 
with  the  means  of  closing  the  broadest  gateway  through  which  the  fatal 
issues  of  these  affections  may  enter,  and  the  consummation  so  devoutly 
to  be  wished  is  more  nearly  to  be  attained  than  it  could  be  in  any  other 
way. 

The  day  is,  I  think,  not  far  distant  when  it  will  become  a  cardinal  rule 
in  the  treatment  of  every  disease  to  maintain  throughout  its  course  the 
temperature  at  or  under  100°.  In  my  own  practice  that  day  has  already 
arrived.  As  I  have  already  said,  observation  and  experience  have  fixed 
the  fact  which  I  am  here  upholding  in  my  mind  as  one  of  the  most  im- 
portant in  the  whole  field  of  therapeutics.     I  am  as  thoroughly  convinced 


80  MEANS    OF    DIAGNOSIS. 

of  its  truth,  and  I  as  sincerely  believe  in  it  as  I  do  in  the  efficacy  of  the 
cinchona  salts  in  malarial  diseases. 

Its  value  was  clearly  pointed  out  years  ago  by  Curry  of  England,  and 
some  may  regard  it  as  an  evidence  adverse  to  its  claims  that  it  was  soon 
obliterated  from  the  professional  mind.  This  objection,  weak  in  itself,  is 
annihilated  by  the  fact  that  Curry,  at  the  same  time  and  with  a  like  futility 
of  result,  urged  the  claims  of  the  greatest  medical  discovery  of  the  last 
century,  one  which,  from  the  standpoint  of  utility  to  medicine  and  through 
it  to  humanity,  equals  in  importance  vaccination  and  anaesthesia — clinical 
thermometry. 

As  the  method  for  accomplishing  control  of  temperature  is  fully  described 
under  the  head  of  ovariotomy,  I  shall  not  allude  further  to  it  here,  but 
refer  the  reader  there. 


CHAPTER  V. 

DIAGNOSIS  OF  THE  DISEASES  OF  THE  FEMALE  GENITAL  ORGANS. 

The  diagnosis  of  the  diseases  of  the  pelvic  viscera  of  the  female  offers 
many  obscurities,  and  frequently  foils  the  most  careful  and  capable  prac- 
titioners. With  the  utmost  caution,  assisted  by  the  most  practised  skill, 
no  one  can  avoid  occasional  errors,  while  in  the  experience  of  those  not 
possessing  these  qualifications,  they  must  be  frequent  and  glaring.  The 
only  safeguard  which  can  be  established  against  their  occurrence,  and  the 
only  guarantee  which  can  be  obtained  for  success  in  prognosis  and  treat- 
ment, is  the  thorough  mastery  of  the  subject  which  is  now  to  engage  us. 

It  is  not  rare  for  one  making  a  special  study  of  gynecology  to  find  those 
less  familiar  with  it  committing  errors  of  diagnosis,  or,  what  is  more  com- 
mon, arriving  at  no  conclusion,  in  cases  which  are  perfectly  simple  and 
present  no  obscurities  whatever.  "When  meeting  such  instances  in  the 
practices  of  intelligent  men,  I  have  been  struck  by  the  fact  that  the  source 
of  difficulty  is  almost  always  the  same.  The  failure  of  diagnosis  has  not 
been  due  to  their  having  drawn  incorrect  conclusions  from  diagnostic 
means,  but  to  their  not  having  brought  these  means  fully  into  action,  and 
properly  applied  them  to  the  solution  of  the  case  in  hand.  In  many  in- 
stances, uterine  disease  being  suspected,  the  physician  employs  vaginal 
touch,  and  follows  it  by  the  speculum.  If  the  os  and  cervix  be  diseased, 
he  is  successful  in  diagnosis;  but  if  not,  he  becomes  discouraged,  forgetful 
of  the  fact  that  rectal  touch,  the  uterine  probe,  dilatation  by  tents,  con- 
joined manipulation,  and  other  means  should  be  resorted  to,  and  that, 
without   appealing  to  these,  even  the  most  skilful  diagnostician  would  be 


MEANS    OF    DIAGNOSIS.  81 

as  helpless  as  himself.  There  are  means  at  our  command  for  exploring 
every  tissue  within  the  pelvis — the  uterus,  the  ovaries,  the  areolar  tissue, 
etc.  ;  and  until  they  are  brought  into  service  carefully,  systematically,  and 
thoroughly,  no  one  can  feel  that  he  has  done  justice  to  his  powers  of  diag- 
nosis, or  allowed  himself  full  opportunity  for  drawing  correct  conclusions. 
Skill  in  diagnosis  must  be  obtained  at  the  bedside,  but  for  that  school  to 
be  made  profitable,  the  student  must  have  a  thorough  familiarity  with  the 
theory  of  the  means  of  investigation  which  he  is  there  to  apply.  Having 
mastered  these,  let  him  in  an  obscure  case  develop  them  one  after  the  other, 
slowly,  carefully,  and  thoughtfully,  until  he  has  arrived  at  a  diagnosis,  or 
at  the  fact  that  he  is  unable  to  make  one  even  after  having  availed  himself 
of  all  the  resources  at  his  command. 

Let  me  illustrate  this  by  a  supposititious  case.  An  inexperienced  ex- 
aminer discovers  upon  vaginal  touch  that  the  vagina  is  occupied  by  a  large 
tumor.  If  he  rest  satisfied  with  this  method  of  exploration,  and  without 
reflection  adopt  the  idea  that  the  case  is  one  of  fibrous  polypus,  he  may 
commit  a  grave  error.  The  most  skilful  of  gynecologists  could  not  decide 
by  touch  alone,  and  would  be,  almost  as  much  as  he,  exposed  to  error  if 
he  relied  upon  it.  All  the  means  which  the  experienced  diagnostician  can 
bring  to  his  aid  are  likewise  at  the  service  of  the  inexperienced ;  and  if 
the  former  stand  in  need  of  their  assistance,  surely  the  latter  much  more 
decidedly  requires  it.  Let  him  then  ask  himself  this  question,  although 
he  may  feel  absolutely  positive,  altogether  certain,  that  he  is  dealing  with 
a  fibrous  polypus  :  what  else  may  this  be  ?  At  once  the  answer  will  come, 
it  may  be  a  case  of  prolapsed  uterus,  or  of  inversion  of  the  uterus.  It  is 
important  that  he  should  know  which  it  is,  and  usually  it  is  quite  easy  to 
decide. 

Drawing  down  the  tumor,  he  examines  by  inspection  and  touch,  and 
seeks  the  os  externum,  up  which  to  pass  the  sound.  It  is  not  anywhere 
to  be  found,  and  moreover  the  tumor  is  larger  below  than  it  is  above.  The 
case  is  not  one  of  prolapsus,  and  he  feels  that  his  diagnosis  of  polypus  is 
surely  correct.  If  it  be  a  polypus  which  occupies  the  vagina,  the  uterus 
should  be  above  it.  He  now  practises  conjoined  manipulation,  but  to  his 
surprise  this  organ  is  nowhere  to  be  felt.  This  may  be  due  to  his  want 
of  experience,  and  he  examines  further  with  the  sound,  endeavoring  to 
pass  it  alongside  of  the  neck  of  the  tumor,  and  into  the  uterine  cavity. 
He  is  surprised  again,  to  find  that  it  is  arrested  at  the  neck  of  the  tumor, 
around  which  he  now  passes  his  finger,  and  finds  it  closed  everywhere  by 
a  gutter  of  circular  character  existing  about  an  inch  above  the  lips  of  the 
dilated  os.  The  case  now  looks  like  one  of  inversion,  but  he  is  not  sure, 
for  sometimes  adhesive  inflammation  attaches  the  walls  of  the  cervix  to 
the  neck  of  the  polypus.  Are  there  any  means  by  which  he  may  settle 
this  question  positively  ?  By  conjoined  manipulation  he  thinks  that  he 
G 


82  MEANS    OF    DIAGNOSIS. 

feels  a  ring  or  circle  over  the  abdominal  face  of  the  tumor,  and  gradually 
he  pushes  his  fingers  into  it,  and  becomes  positive  of  its  existence. 

Now  placing  the  patient  upon  the  back  he  passes  one  finger  into  the 
rectum  and  a  sound  into  the  bladder  and  approximates  them  above  the 
tumor.  He  finds  no  uterus  intervening,  and  his  diagnosis  is  made;  the 
case  is  one  of  inversion  of  the  uterus.  This  is  his  diagnosis,  that  is,  his 
deduction  carefully  and  philosophically  drawn  from  the  premises  presented 
to  him,  by  the  best  means  at  his  disposal.  Let  him  resort  to  all  these 
means,  and  success  will  usually  be  his.  But,  it  may  be  suggested,  he  is 
not  as  familiar  witli  these  means  as  a  more  experienced  man  is.  Practi- 
cally, I  agree  that  he  is  not ;  but  why  is  he  not  theoretically  ?  Are  they 
not  recorded  and  fully  explained  in  all  his  works  on  gynecology?  What 
is  demanded  of  him  is  not  experience,  not  wisdom  ;  but  a  faithful  and 
earnest  effort  to  arrive  at  the  truth  by  simply  employing  means  which 
science  places  at  his  disposal. 

These  remarks  of  course  apply  with  equal  force  to  every  condition  in 
which  a  diagnosis  is  required.  Let  it  be  a  constant  habit  to  demand  of 
one's  self,  after  admitting  a  suspicion  as  to  the  nature  of  the  disease,  what 
else  could  present  the  physical  appearances  which  exist  ?  Having  care- 
fully considered  this,  let  the  various  means  of  differentiation  at  command 
be  fully  tested.  Then  if  an  error  of  diagnosis  creep  in  to  damage  interests 
entrusted  to  his  charge,  the  mortified  diagnostician  may  console  himself 
with  the  reflection  that  at  least  he  has  exerted  himself  to  the  utmost  of  his 
ability  to  avoid  it,  and  not  fallen  into  a  trap  set  for  him  by  carelessness, 
indolence,  or  incompetency. 

It  must  not  be  forgotten,  however,  that  certain  rare  and  exceptional 
cases  will  occasionally  occur,  the  diagnosis  of  which  will  baffle  the  skill 
and  experience  of  the  most  cautious  and  conscientious.  Take,  for  example, 
the  following  :'  a  patient  aged  sixty-two  years  had  a  movable  abdominal 
tumor  which  was  examined  by  a  number  of  physicians.  She  died  suddenly 
and  autopsy  revealed  extra-uterine  pregnancy,  a  child  weighing  four  and 
a  half  pounds  lying  loose  in  the  peritoneal  cavity.  Or  this  :2  a  tumor  is 
discovered  in  the  pelvis ;  the  patient  dies  from  some  cause  disconnected 
with  it,  and  it  is  found  to  be  a  displaced  kidney.  But  such  cases  are  rare. 
The  careful  and  intelligent  diagnostician  will  very  generally  be  successful. 

Rational  Signs. 

In  the  examination  of  a  patient  suspected  of  having  uterine  disorder  no 
direct  or  suggestive  questions  should  be  asked,  but  the  symptoms  should 
be  drawn  forth  by  encouraging  and  properly  directing  her  narrative  of  her 
case.     Certain  signs,  which  we  call  "  rational,"  from  their  appealing  to 

1  N.  Y.  Med.  Record,  Feb.  1st,  1872,  p.  539. 

2  Braithwaite's  Retrospect,  part  37. 


RATIONAL    SIGNS.  83 

our  reason  and  not  to  our  senses,  such  as  pain  in  the  head,  back,  and 
limbs,  menstrual  disorder,  leueorrhcea,  impeded  locomotion,  derangement 
of  the  digestion,  and  nervous  manifestations,  will  lead  us  to  suspect  the 
genital  organs,  and  may  even  convince  us  of  the  existence  of  disease  there. 
Generally,  however,  they  result  in  the  adoption  of  other  and  more  certain 
means  of  diagnosis,  which  are  termed  "  physical." 

Every  one  will,  after  due  experience,  adopt  some  system  by  which  his 
examination  of  patients  will  be  expedited,  and  the  certainty  of  arriving  at 
a  correct  diagnosis  be  increased.  The  plan  which  I  consider  best  adapted 
to  these  ends  is  that  which  follows : — 

1st.  The  personal  history,  age,  etc.,  of  the  patient  should  be  obtained. 

2d.  The  duration  of  the  illness  should  be  fixed. 

3d.  The  history  of  the  attack  from  commencement  to  date  should  be 
elicited. 

4th.  The  present  state  of  the  patient  should  be  ascertained. 

In  obtaining  the  history  of  the  disease,  no  leading  questions  have  thus 
far  been  asked  ;  the  patient  has  told  us  what  she  herself  has  observed.  Her 
evidence  leads  us  to  suspect  some  special  disorder,  and  then  we  proceed 
thus : — 

5th.  Direct  questions  are  put  with  the  intent  of  testing  the  correctness 
of  the  suspicion  which  the  patient's  story  has  excited. 

Gth.  Physical  means  are  brought  to  the  corroboration  of  the  diagnosis  by 
rational  ones. 

Forms,  either  written  or  printed,  such  as  that  which  follows,  will  not 
only  save  a  vast  deal  of  time  and  trouble,  but  give  uniformity  to  histories 
taken,  so  that  after  a  number  of  them  have  been  accumulated  they  may 
be  collated  with  reference  to  special  points,  or  preserved  for  personal  ref- 
erence or  publication. 

Case,  No. Date, 

Name Age Married  ? 

No.  of  children -    No.  of  abortions Time  since  last 

pregnancy Age  at  which  menstruation  appeared 

Duration  of  present  illness Symptoms  during  its  course 


Supposed  cause 


84  MEANS    OP    DIAGNOSIS, 

Present  condition  as  regards 

(  Regularity 

Menstruation,   -<  Amount - 

(Pain 

(Character 

Leucorrhoea,      -l  Amount 


(  Constancy . 
Pain  (Locality- 

•rain'  (Degree 

Locomotion 

Other  symptoms 


(  By  touch 

Physical  signs,  <  By  speculum 
(  By  probe 


Diagnosis  — 
Treatment 


It  will  be  observed  that  I  have  not  enumerated  the  various  rational 
signs  generally  attendant  upon  uterine  affections,  but  merely  the  means 
for  drawing  them  forth.  Their  special  mention  will  be  reserved  for  the 
study  of  particular  affections.  If  the  evidence  elicited  leaves  any  of  the 
pelvic  viscera  under  suspicion,  this  is  verified  or  removed  by  means  which 
are  more  positive  and  reliable  from  the  fact  that  they  address  our  senses. 

It  will  further  be  seen  that  the  headings  of  my  table  are  not  numerous, 
nor  the  table  itself  lengthy  or  exhaustive.  My  belief  is  that  the  chief 
reason  why  such  tables  are  not  more  generally  employed  is  that  they  are 
so  long  and  so  filled  with  non-essential  items  as  to  become  tedious  and 
impracticable.  This  table  is  that  which  I  employ  in  daily  practice.  I 
find  that  when  filled  out  it  gives  all  the  salient  points  in  my  cases,  and 
these  are  all  that  I  desire  ordinarily  to  preserve. 

Management  of  Patient  during  Physical  Examination Be- 
fore commencing  the  consideration  of  physical  signs,  I  shall  make  a  few 
remarks  upon  a  subject  of  great  importance  in  this  connection,  namely, 
the  management  of  the  patient  during  the  examination.  As  Dr.  Sims 
has  taught  us,  she  should  never,  unless  it  be  impossible  to  do  otherwise, 
be  examined  upon  a  bed  or  sofa,  but  upon  a  table  covered  with  a  blanket, 
shawl,  or  rug  of  some  kind,  and  provided  with  a  small  pillow.  The  facility 
thus  given  for  thorough  investigation  is  very  great,  and  the  avoidance  of 
the  sinking  of  the  body  into  the  soft  bed  repays  most  fully  the  extra 
trouble  which  it  causes  to  make  the  change.  It  may  be  said  that  many 
ladies  will  strongly  object  to  the  exposure  incident  to  getting  upon  a  table. 
This  is  not  so;  a  little  persuasion  will  overcome  such  objections  at  once, 
and  the  increased  exposure  is  in  reality  imaginary,  for  the  table  is  to  all 
intents  a  bed,  and  a  sheet  for  covering  the  person  gives  all  desirable  pro- 


MANAGEMENT    OF    PATIENT    DURING    EXAMINATION, 


85 


tection.  Should  it  be  necessary  to  employ  a  bed,  the  leaf  of  a  dining-table 
or  a  wide  board  should  be  slipped  across  the  mattress  under  the  upper 
sheet  and  covering,  and  a  hard  surface  will  thus  be  presented  for  the  pa- 
tient to  lie  upon,  which  will  obviate,  in  great  degree,  the  objections  to  the 
bed  otherwise  arranged. 

The  patient  should  always  lie  upon  her  back  in  a  first  examination,  with 
the  clothing  loose  around  the  waist,  the  knees  drawn  up,  and  the  abdomi- 
nal walls  relaxed.  A  sheet  should  be  spread  over  her  so  as  to  conceal  the 
entire  person.  The  table  having  been  previously  turned  to  a  window  ad- 
mitting a  strong  light,  a  chair  should  be  placed  at  its  foot  for  the  examiner, 
and  at  the  right  side  of  it  another,  upon  which  has  been  arranged  a  basin 
of  warm  water,  soap,  and  a  towel. 

A  variety  of  tables  for  these  examinations  in  the  physician's  office  are 
now  before  the  profession.  I  here  present  that  which  I  employ  both  in 
otfice  and  hospital  practice.  For  the  cylindrical  speculum  it  presents  the 
advantages  of  an  ordinary  table  ;  for  Sims's  speculum,  a  great  many  more. 


Fig.  6. 


Thomas's  gynecological  table. 


Fig.  G  represents  the  table  prepared  for  an  examination  on  the  back  ;  a 
pillow  supports  the  head,  the  buttocks  are  slightly  elevated,  and  the  feet 
rest  upon  the  projecting  pieces.  When  this  examination  is  completed,  the 
patient  stands  upon  the  chair  or  stool  recently  occupied  by  the  examiner, 
and  the  table  is  changed  for  examination  with  the  speculum  in  Sims's  posi- 
tion, as  shown  in  Fig.  7.  The  top  of  the  table  is  now  elevated  at  one  side 
so  that  it  slants  decidedly  to  the  other.  The  ankles  of  the  patient,  resting 
one  upon  the  other,  are  supported  by  the  projecting  pad  upon  the  end  of 
the  foot-piece.  The  other  foot-piece  has  now  been  pushed  into  the  body 
of  the  table.     This   position,  by  gravitation,  throws  forwards  the  viscera, 


86 


MEANS    OF    DIAGNOSIS. 


and  thus  aids  in  rendering  the  action  of  Sims's  speculum  more  perfect.  It 
will  be  observed  that  the  slanting  surface  of  the  table  is  now  supported  by 
the  hinged  piece  which  in  Fig.  6  lies  as  a  flap  along  the  side  of  the  table, 
but  in  Fig.  7  is  turned  up. 

Fig.  7. 


Thomas's  gynecological  tabic. 


Means  of  Physical  Diagnosis. 

I  shall  enumerate  and  consider  these  in  the  order  in  which  they  will 
generally  be  employed  in  a  case  requiring  the  aid  of  all  of  them  for  its 
elucidation: — 

1.  Anaesthesia. 

2.  Vaginal  touch. 

3.  Conjoined  manipulation. 

4.  Abdominal  palpation. 

5.  Abdominal  palpation  conjoined  with  use  of  the  sound. 
G.   Inspection. 

7.  Rectal  touch. 

8.  Vesico-rectal  exploration. 

9.  The  speculum. 

10.  The  uterine  probe  and  sound. 

11.  The  elastic  sound. 

12.  Tents. 

13.  The  wire  loop. 

14.  The  exploring  needle. 
li).  The  aspirator. 

10.  The  microscope. 

17.  Auscultation  and  Percussion. 


VAGINAL    TOUCH.  87 

Anaesthesia This  should  not  be  resorted  to  unless   there  be  some 

special  indication  for  it.  Should  the  patient  be  intractable,  delirious,  or  a 
malingerer;  should  the  investigation  involve  much  severe  pain  ;  or  should 
there  be  some  tonic  spasm  of  the  muscles  as  an  element  of  the  disease,  as 
is  the  case  in  spurious  pregnancy  and  phantom  tumors,  it  affords  an  aid  to 
diagnosis  of  great  value,  and  should  never  be  neglected.  When  we  are 
forced  to  examine  a  virgin  who  is  very  sensitive,  and  opposed  to  the  in- 
vestigation, it  is  sometimes  advisable,  for  without  it  a  diagnosis  is  fre- 
quently impracticable.  One  even  of  large  experience  is  often  greatly 
surprised  by  the  results  of  two  consecutive  examinations,  the  one  without 
and  the  other  with  anaesthesia.  The  second  not  only  corrects  the  short- 
comings of  the  first,  but  throws  a  flood  of  light  where  obscurity  existed 
before. 

Vaginal  Touch This,  which  will  be  the  first  explorative  measure 

to  which  the  examiner  will  resort,  constitutes  one  of  the  most  important 
at  his  command.  It  will  reveal  much  or  little,  as  it  is  practised  slowly 
and  thoughtfully,  or  hastily  and  as  a  matter  of  routine.  In  making  it  the 
index  finger  of  either  hand  may  be  employed,  and  when  it  is  desirable  to 
reach  as  far  up  the  pelvis  as  possible,  the  index  and  middle  fingers  may 
be  used.  During  this  examination  the  patient  should  invariably  be  laid 
upon  the  back,  with  the  legs  flexed  and  the  buttocks  very  near  the  edge 
of  the  table.  The  observance  of  this  position  is  of  great  importance,  as 
vaginal  touch  should  in  every  case  be  combined  with  abdominal  palpation, 
to  which  union  the  name  of  conjoined  manipulation  or  bimanual  palpation 
has  been  applied. 

The  index  finger  of  one  hand,  being  introduced  into  the  vagina,  the 
other  fingers  being  flexed  into  the  palm  and  the  thumb  laid  upon  them, 
passes  directly  to  the  cervix  uteri,  assuring  the  investigator,  as  it  goes,  of 
the  perviousness  of  the  vaginal  canal.  Upon  reaching  the  os,  this  part  is 
carefully  examined  with  reference  to  size,  consistency  of  lips,  and  charac- 
ter of  discharge  ;  a  patulous  os,  with  soft,  velvety  sides  covered  by  a  glu- 
tinous secretion,  admonishing  him  of  the  existence  of  inflammation  of  the 
os  and  cervical  canal.  The  cervix  should  then  be  examined  with  refer- 
ence to  location,  size,  and  density.  This  being  done,  the  finger  should  be 
slid  along  its  posterior  surface  into  the  recto-uterine  space,  and  the  pres- 
ence of  any  hardness  or  tumefaction  there  be  noted.  Should  such  be 
found,  it  will  probably  be  due  to  one  of  these  causes,  retroflexion  or  retro- 
version of  the  uterus,  uterine  enlargement,  a  fibrous  tumor,  scybake  in  the 
rectum,  inflammatory  products,  the  result  of  peri-uterine  cellulitis  or  peri- 
tonitis, a  prolapsed  ovary  or  ovarian  tumor,  or  an  hematocele.  Should  no 
tumor  be  discovered,  but  the  line  of  resistance  given  to  the  finger  be  found 
to  disappear  at  the  vaginal  junction  with  the  uterus,  it  may  be  inferred 


88  MEANS    OF    DIAGNOSIS. 

with  moderate  certainty  that  at  this  point  none  of  the  above  mentioned 
conditions  exist. 

This  space  being  explored,  the  finger  should  then  be  passed  anteriorly, 
and  swept  upward  and  forward  along  the  base  of  the  bladder  toward  the 
symphysis  pubis.  Any  hardness  discovered  here  will  probably  be  due  to 
anteflexion  or  anteversion  of  the  uterus,  a  fibrous  tumor,  stone  in  the 
bladder,  uterine  enlargement,  or  possibly  cellulitis. 

The  state  of  the  ovaries  should  then  be  tested  by  lateral  pressure,  and 
the  condition  of  the  pelvic  areolar  tissue  and  walls  by  firm  pressure  in  all 
directions. 

In  certain  rare  and  obscure  cases,  such,  for  example,  as  those  in  which 
a  diagnosis  of  large  tumors  in  the  vagina  is  very  difficult,  it  becomes 
necessary  to  introduce  the  whole  hand  into  the  vagina.  This  procedure, 
which  should  be  resorted  to  while  the  patient  is  anaesthetized,  must  be 
practised  with  the  greatest  caution.  Otherwise  injury  may  be  done  to 
the  parts  about  the  vulva,  and  a  large  and  carelessly  managed  hand  may 
produce  rupture  of  the  vagina. 

One  manoeuvre,  by  which  touch  of  the  parts  lying  closely  in  contact 
with  Douglas's  cul-de-sac  is  much  facilitated,  still  remains  to  be  mentioned. 
"Where  small  tumors  exist  behind  and  disconnected  with  the  uterus,  or 
where  enlarged  and  prolapsed  ovaries  are  to  be  sought  for  and  examined, 
an  excellent  result  is  often  obtained  by  placing  the  patient  in  Sims's  left 
lateral  position,  and  passing  the  index  and  middle  fingers  of  the  right  hand 
as  high  up  as  possible,  their  palmar  surfaces  looking  towards  the  posterior 
wall  of  the  vagina.  By  this  method  I  have  repeatedly  detected  enlarged 
and  slightly  displaced  ovaries  which  in  the  dorsal  decubitus  had  entirely 
escaped  observation. 

Conjoined  Manipulation,  oh  Bimanual  Palpation As  the  pre- 
ceding examination  consists  in  touching  organs  above  the  pelvic  roof  for 
the  most  part,  and  which  are  generally  quite  movable,  it  is  evident  that 
its  results  are  diminished  by  ascent  of  these  parts  as  they  are  pressed  upon. 
To  bring  them  more  fully  within  the  reach  of  the  finger  in  the  vagina, 
and  to  prevent  their  retreat,  abdominal  palpation  should  invariably  be 
combined  with  vaginal  touch.  While  the  latter  is  being  performed  by  the 
index  finger  of  one  hand,  the  other  hand  should  be  placed  on  the  abdomen, 
and  by  it  the  uterus  be  made  to  descend,  so  that  even  its  upper  parts  may 
become  accessible.  This  will  enable  the  examiner  to  sweep  the  finger  in 
the  vagina  over  the  posterior,  anterior,  and  lateral  surfaces  of  the  organ, 
and  detect  the  presence  of  any  enlargement,  sensitiveness,  or  abnormal 
growth  there.     Fig.  8  represents  this. 

But  not  only  should  the  walls  of  the  uterus  be  thus  explored :  the  vol- 
ume, shape,  sensitiveness,  and  regularity  of  surface  of  this  organ,  as  well 
as  of  the  ovuries,  the  broad  ligaments,  anterior  vaginal  wall,  and  bladder, 


ABDOMINAL    PALPATION, 


89 


should  likewise  be  ascertained.  To  accomplish  this  with  reference  to  the 
uterus,  let  the  finger  in  the  vagina  be  placed  under  it — anterior  to  the 
cervix  if  it  be  in  normal  position  or  antellexed,  posterior  to  it  if  it  be  re- 
troflexed — and  the  organ  will  be  distinctly  felt  resting  between  it  and  the 
lingers  which  depress  the  abdominal  wall.  By  the  same  method  the  other 
parts  mentioned  should  be  examined.     Conjoined  manipulation  is  of  great 

Fig.  8. 


Practice  of  conjoined  manipulation.     (Sims  ) 

importance  ;  indeed  no  examination  can  be  considered  complete  without 
it.  By  a  neglect  of  this  seemingly  trifling  precaution  I  have  known  the 
existence  of  large  tumors,  and  even  of  pregnancy  quite  advanced,  entirely 
ignored.  Some  time  ago  a  physician  sent  to  me  from  a  distance  a  case 
which  he  supposed  to  be  one  of  prolapsus  uteri,  from  the  fact  that  the  ute- 
rus was  low  in  the  pelvis,  never  suspecting  for  a  moment  the  existence  of 
two  fibrous  tumors,  each  the  size  of  a  foetal  head,  which  depressed  the 
displaced  organ. 

Were  I  called  upon  to  mention  the  most  important  method  of  diagnosis 
at  the  disposal  of  the  gynecologist,  not  excepting  the  speculum  and  sound, 
or  even  tlie  two  of  them  together,  I  should  unhesitatingly  select  conjoined 
manipulation.  It  is  less  generally  known,  and  much  less  generally  appre- 
ciated than  it  deserves  to  be. 

Not  only  may  this  method  be  practised  by  combination  of  vaginal  touch 
with  abdominal  palpation  :  it  may  likewise  consist  of  the  combination  of 
the  latter  with  rectal  touch,  by  one  finger,  or  by  the  introduction  of  the 
hand  after  Simon's  method. 


Abdominal    Palpatiox The   practice  of  bimanual   palpation  will 

have  assured  the  investigator  of  the  presence  of  any  tumors  which  may 


90  MEANS    OF    DIAGNOSIS. 

exist  in  the  pelvis.  Should  such  have  been  discovered,  a  further  exami- 
nation will,  of  course,  at  once  be  entered  upon  to  ascertain  their  size, 
shape,  attachments,  and  contents.  In  this  exploration  both  hands  are 
employed  externally,  and  by  them  firm  pressure  is  made  and  the  abdomi- 
nal walls  depressed,  so  that  by  grasping  the  masses  their  characters  may 
be  appreciated.  By  this  means  the  diagnostician  decides  as  to  the  solidity 
or  fluidity  of  tumors,  their  sensitiveness  to  pressure,  the  presence  of  foetal 
movements,  and  other  points  of  ecpjal  importance. 

Abdominal  Palpation  conjoined  with  the  use  of  the  Sound 

I  shall  very  soon  speak  of  the  uterine  sound  in  relation  to  its  ordinary  and 
more  legitimate  functions.  Here  I  allude  to  it  only  as  a  means  of  rotating 
the  uterus  in  the  pelvis  in  order  that  the  hand  pressed  upon  the  abdomen 
may  separate  it  from  enlargements  in  the  abdomen.  This  method  of  in- 
vestigation is  of  so  great  value,  and  appears  to  me  so  little  appreciated  and 
so  rarely  practised,  that  I  wish  to  draw  especial  attention  to  it.  Let  us 
suppose  that  a  tumor  occupies  the  pelvis  or  lower  portion  of  the  abdomen, 
and  it  be  desired  to  determine  how  close  a  relation  exists  between  it  and 
the  uterus.  The  sound  being  passed  to  the  fundus,  the  patient  lying  upon 
the  back,  it  is  made  to  rotate  the  uterus.  The  left  hand,  which  is  unoc- 
cupied, is  now  placed  on  the  abdomen,  so  as  to  become  cognizant  of  move- 
ments in  the  uterus  and  tumor.  If  both  move  equally,  their  connection  is 
intimate;  if  the  uterus  move  freely  and  the  tumor  but  little,  it  is  less 
marked;  while  if  the  tumor  remains  stationary  during  rotation  of  the  ute- 
rus, there  is  probably  no  connection,  or  one  only  by  lengthy  bonds  of  union. 

Again,  in  cases  where  palpation  and  conjoined  manipulation  fail  to  map 
out  the  position  of  the  uterus  on  account  of  obscure  pelvic  tumors  or  great 
obesity  of  the  woman,  lifting  the  organ  by  the  sound  and  rotating  it  under 
the  palm  laid  upon  the  abdomen,  is  a  valuable  resource. 

Lastly,  in  cases  of  supposed  fibrous  polypus  where  one  fears  to  operate 
lest  an  inverted  uterus  may  have  misled  him,  although  the  passage  of  the 
sound  alone  makes  him  almost  sure  as  to  diagnosis,  it  gives  confidence  to 
feel  the  uterine  body  rolling  under  the  hand  laid  over  the  abdomen,  for  it 
is  not  an  unheard  of  occurrence  for  the  sound  to  pass  through  the  uterine 
walls  and  enter  the  peritoneum. 

I  would  urge  this  procedure,  as  a  rule,  in  the  examination  of  abdominal 
and  pelvic  tumors.  Indeed,  in  a  large  number  of  such  cases,  a  neglect  of 
it  will  allow  of  errors  in  diagnosis,  which,  by  its  adoption,  might  have 
been  avoided. 

Inspection. — A  great  deal  may  be  learned  from  the  inspection  of  dis- 
e:i><  <1  growths  about  the  vulva,  or  ostium  vaginae,  and  of  tumors  in  the 
vagina,  which  may  be  drawn  down  between  the  labia,  and  valuable  infor- 
mation may  be  gained  concerning  abdominal  enlargements  by  this  means. 


RECTAL    TOUCH.  91 

For  example,  the  shape  of  an  ovarian  cyst  is  globular  and  protuberant, 
while  that  of  an  abdomen  affected  by  ascites  is  flat  and  bulging  at  the 
sides  ;  the  form  of  a  mono-cyst  is  usually  globular,  while  that  of  a  poly- 
cyst  is  commonly  irregular;  the  development  of  a  pregnant  uterus  is  regu- 
lar and  symmetrical ;  that  of  a  solid  tumor  of  the  uterus  often  irregular 
and  unsymmetrical. 

Rectal  Touch Should  anything  have  been  discovered  upon  either 

uterine  wall  to  make  further  light  upon  the  state  of  these  parts  desirable, 
or  should  symptoms  have  presented  themselves  which  excite  suspicion  of 
the  presence  of  some  morbid  growth,  the  index  finger  of  one  hand  should 
be  carried  far  up  into  the  rectum,  and,  if  necessary  to  enable  it  to  reach 
the  posterior  uterine  wall,  a  tenaculum  should  be  fixed  in  the  cervix,  and 
by  gentle  traction  the  organ  drawn  down.  Generally,  however,  sufficient 
depression  will  be  accomplished  by  firm  pressure  over  the  hypogastrium  with 
the  other  hand,  the  tips  of  the  fingers  pressing  the  uterus  towards  the  floor 
of  the  pelvis  ;  or  both  of  these  means  may  be  combined  by  bringing  to  our 
aid  the  hand  of  an  assistant.  Those  who  have  not  employed  this  method 
systematically  must  have  a  faint  idea  of  the  great  facility  which  it  gives 
for  exploration  of  the  lower  portion  of  the  posterior  wall  and  recto-uterine 
space. 

Prof.  Simon,  of  Heidelberg,  some  years  ago  greatly  modified  the  method 
of  exploring  the  pelvic  viscera  of  the  female  through  the  rectum.  His 
method  is  thus  put  into  practice: — 

1st.  The  patient  is  anaesthetized  and  placed  in  an  exaggerated  lithotomy 
position  ;  the  knees  being  thrown  upwards  so  as  to  flex  the  thighs 
sharply. 

2d.  The  sphincter  ani  is  thoroughly  stretched,  and  first  the  fingers  and 
then  the  hand  cautiously  introduced.  In  certain  very  rare  cases  an  in- 
cision, involving  the  sphincter,  is  made  through  the  posterior  raphe  of  the 
anus.      For  diagnostic  purposes  this  is  very  seldom  required. 

3d.  The  fingers  are  then  separated  and  a  careful  examination  of  the 
pelvic  organs  is  made. 

4th.  Should  it  be  found  necessary  to  invade  the  parts  above  the  level 
of  the  sacrum,  three  or  four  fingers  are  introduced  into  the  sigmoid  flexure, 
so  that  we  may  "  reach  above  the  umbilicus  without  in  the  least  injuring 
the  intestines  or  peritoneum,  and,  the  upper  portion  of  the  rectum  and  sig- 
moid flexure  being  extremely  movable,  can  palpate  the  whole  abdomen  as 
far  as  the  lower  edge  of  the  kidney." 

It  was  asserted  that  by  this  means  a  positive  diagnosis  could  be  made 
of  many  diseased  states  of  the  uterus,  ovaries,  rectum,  and  sometimes  even 
of  the  kidneys  ;  that  by  it  the  examiner  is  enabled  to  hold  the  ovaries 
between  the  thumb  and  finger  and  appreciate  their  size,  consistence,  and 
smoothness  ;  to  discover  tumors  of  the  uterus  no  larger  than  a  cherry  ;  to 


92  MEANS    OF    DIAGNOSIS. 

ascertain  the  length  of  the  pedicle  of  an  ovarian  cyst,  and  the  freedom  from 
attachments  of  the  cyst  itself;  and  in  a  case  of  renal  cyst  to  learn  that  the 
tumor  has  no  connection  with  the  pelvic  organs. 

Such  is  Simon's  method  of  rectal  exploration.  In  an  edition  of  this 
work  published  six  years  ago,  I  advocated  it,  basing  my  views  chiefly 
upon  the  assertions  of  its  originator,  and  to  a  limited  extent  upon  personal 
experience.  To-day  with  fuller  experience  I  maintain  that,  except  in  a 
very  few  rare  cases,  it  should  be  expunged  from  the  list  of  explorative 
measures  in  gynecology.  That  in  certain  exceptional  cases  it  may  have 
to  be  resorted  to,  I  do  not  deny  ;  but  even  in  these  it  should  be  employed 
with  the  greatest  caution,  and  be  regarded  in  the  light  of  a  serious  ope- 
rative procedure.  It  is  attended  by  too  great  danger  of  laceration  of 
the  wall  of  the  intestine,  and  cramps  the  hand  so  as  to  give  too  little 
explorative  power  in  proportion  to  the  risk  run  to  warrant  a  frequent 
resort  to  it. 

Several  cases  are  now  on  record  in  which  its  employment  in  the  hands 
of  careful  and  skilful  practitioners  has  terminated  fatally.  The  danger  is 
greatly  increased  where  several  examiners  succeed  each  other  in  explora- 
tion. The  earlier  examinations  stretch  and  weaken  the  tissues,  and  the 
later  lacerate  them.  For  this  reason  it  should  be  made  a  rule  that  only 
one  exploration  should  be  made,  and  that  that  should  last  only  a  short 
time. 

A  great  deal  more  can  be  accomplished  by  the  introduction  of  the  hand 
except  the  thumb,  after  stretching  the  sphincter  ani,  than  by  the  old  method 
of  introducing  only  one  or  two  fingers. 

Should  any  substance  lie  in  the  recto-vaginal  space,  its  character  may 
be  accurately  appreciated  by  what  has  been  styled,  by  Dr.  Tilt,  the 
"  double  touch,"  which  consists  in  introducing  the  index  finger  into  the 
rectum  and  the  thumb  into  the  vagina,  and  then  approximating  them.  Or 
the  index  of  one  hand  may  be  introduced  into  the  vagina  and  that  of  the 
other  into  the  rectum. 

Vesico-rectal  Exploration This  consists  ordinarily  in  passing  a 

catheter  or  sound  into  the  bladder,  and  pressing  it  towards  the  index 
finger  in  the  rectum.  Its  scope  is  not  extensive,  but  for  some  purposes  no 
other  method  answers  the  same  end,  as,  for  example,  for  the  following : — 

Appreciating  the  size  of  the  uterus  in  very  fat  women ; 

Detecting  absence  of  the  uterus  ; 

Differentiating  inversion  from  polypus. 
The  only  difference  between  this  method  and  conjoined  manipulation 
consists  in  the  attempt  to  grasp  the  uterus  between  the  finger  and  sound 
instead  of  between  the  fingers  of  the  two  hands.  Who  the  originator  of 
this  ingenious  method  is  I  cannot  say.  By  Mr.  C.  F.  Weiss  it  is  attri- 
buted to  Malgaigne. 


THE    SPECULUM.  93 

This  method  may  be  practised  in  still  another  manner ;  that  proposed 
by  Noeggerath.  It  consists  in  dilatation  of  the  urethra  by  graduated  dila- 
tors, the  introduction  of  the  index  finger  of  one  hand  into  the  bladder  and 
that  of  the  other  into  the  rectum  or  vagina,  and  the  approximation  of  these 
so  that  the  uterine  walls,  anterior,  posterior,  and  lateral,  can  be  carefully 
and  thoroughly  examined.  This  method,  like  that  of  Simon,  should  be  re- 
sorted to  only  in  obscure  and  difficult  cases  not  susceptible  of  elucidation 
by  other  means. 

The  Speculum — This  is  by  no  means  our  most  valuable  diagnostic 
resource.  Too  great  a  reliance  upon  it  as  such  is  calculated  to  diminish 
the  physician's  powers  for  arriving  at  a  correct  conclusion  in  obscure 
cases.  Unquestionably  the  greatest  benefits  derived  from  the  speculum 
demonstrate  themselves  in  the  therapeutic  department  of  this  subject. 
As  a  diagnostic  means  it  is  inferior  to  vaginal  and  rectal  touch  combined 
with  abdominal  palpation,  and  chiefly  aids  us  in  this  field  by  opening  the 
way  to  the  proper  use  of  the  uterine  probe,  which  constitutes  one  of  the 
most  reliable  methods  at  our  command  for  appreciating  the  condition  of 
the  cavity  of  the  uterus.  Let  any  one  who  is  surprised  at  the  statement, 
which  many  will  be,  reflect  as  to  what  can  really  be  seen  even  in  aggra- 
vated cases  of  disease,  except  malignant,  granular,  and  cystic  degeneration 
of  the  cervix.  The  position  of  the  uterus,  the  presence  of  a  foreign  body 
in  its  cavity,  the  condition  of  its  surrounding  tissues  can  none  of  them  be 
learned  from  the  sense  of  sight. 

All  vaginal  specula  may  be  classified  under  two  heads,  cylindrical  and 
valvular.  Of  the  first  variety  cylinders  of  metal,  porcelain,  ivory,  and 
wood  are  in  general  use.  None  of  these  compare  in  elegance,  cleanliness, 
and  utility  with  that  of  Dr.  Fergusson,  of  London,  which  consists  of  a  tube 
of  glass  coated  with  quicksilver,  and  covered  by  India-rubber,  which  is 
thoroughly  varnished.     This  instrument  is  represented  in  Fig.  9. 


Fig.  9. 


Fergusson's  speculum. 


Objections  which  attach  to  all  cylindrical  instruments  are  the  following: 
to  suit  all  cases  they  must  be  from  five  to  six  inches  long,  which  renders 
probing  the  uterus  through  them  impossible,  and  prevents  applications  from 
being  carried  to  the  fundus  ;  it  is  not  possible  to  examine  through  them 


94 


MEANS    OF    DIAGNOSIS. 


Fig.  10. 


Thomas's  telescopic  speculum. 


by  touch;  and  in  anteversion  it  is 
difficult  to  get  the  cervix  into  the 
field.  The  instrument  represented 
in  Fig.  10  obviates  many  of  these 
difficulties  by  accommodating  itself 
to  the  length  of  every  vagina,  so 
that  the  shoulders  come  just  be- 
tween the  labia. 
It  consists  of  two  thin  metallic 
tubes,  one  of  which  slides  within  the  other.  To  the  inner  tube  are  at- 
tached, at  the  mouth,  wings  which  sustain  the  labia,  and  the  outer  tube 
ends  in  a  tip  which  is  either  straight  or  curved.  It  is  called  the  "tele- 
scopic speculum,"  from  its  mechanism,  and  measures,  when  not  extended, 
along  its  shorter  side  two  and  a  half  inches,  along  the  opposite,  three. 
"When  extended,  it  is  as  long  as  the  ordinary  cylindrical  specula.  On  both 
surfaces,  upper  and  lower,  are  two  fenestra?,  which  admit  of  elevating  or 
depressing  the  probe  in  cases  where  flexion  or  version  exists,  and  its  han- 
dle must  be  much  lowered.  A  downward  curve  may  with  advantage  be 
given  to  the  longer  lip.  This  curve  looks  at  first  both  odd  and  useless; 
but  upon  experiment  it  will  be  found  to  answer  a  very  useful  purpose. 
In  cases  where  the  uterus  is  normal  in  position  it  will  not  depress  the 
cervix  too  much,  while  by  turning  it  up  when  this  part  lies  imbedded  in 
the  hollow  of  the  sacrum  the  examiner  will  be  enabled  to  lift  it  and  engage 


Fig.  11. 


Cusco's  speculum. 


it  in  the  field  of  the  speculum.  When  fully  introduced  the  wings  at  the 
mouth  of  the  instrument  support  the  labia,  and  thus  no  superfluous  portion 
extends  beyond  the  vulva. 

Of  valvular  specula  the  bivalve  of  Ricord,  the  trivalve  of  Segalas,  and 
the  quadrivalve  of  Charriere  have  long  been  popular.     No  instrument  of 


THE    SPECULUM. 


95 


this  variety  with  which  I  am  acquainted  equals  that  of  M.  Cusco,  Fig.  11. 
It  is  compact,  easily  introduced,  and  shows  the  cervix  very  clearly. 

A  great  many  modifications  of  Cusco's  speculum  are  now  in  use.     In- 
deed so  great  is  the  variety  of  modifications  of  this  and  of  Sims's  instru- 


Fig.  12. 


Howard's  modification  of  Cusco's  speculum. 

ment  that  the  speculum  seems  destined  to  vie  with  the  obstetric  forceps 
in  the  number  of  its  variations.  Fig.  12  represents  Dr.  Howard's  modifi- 
cation of  Cusco's  speculum,  a  very  good  representative  of  its  class. 

Of  all  the  specula  thus  far  mentioned  I   have   spoken  from  personal 
knowledge.     The  next  I  show  upon  faith  alone.     It  is  the  speculum  of 
Prof.  Neugebauer,  of  War- 
saw, which  is  so  highly  com-  *IG*  ™m 
mended  by  some  of  the  most 
eminent     gynecologists      of 
Great   Britain  that  I  bring 
it    before    the    reader    upon 
their    authority.     The    dia- 
gram here  exhibited  shows 
this    instrument    somewhat 
modified  by  Dr.  Barnes,  of 
London,  and  as  presented  by 
him  before  the  London  Ob- 
stetrical Society. 

All  valvular  specula,  how- 
ever, present  these  great  disadvantages.  It  is  difficult  to  avoid  prolapse 
of  the  vaginal  wall  between  their  branches,  and  in  removing  the  instru- 
ment these  are  liable  to  be  painfully  pinched.  If,  upon  introducing  and 
expanding  their  branches,  the  os  uteri  is  exposed,  all  goes  well ;  but  if  it 
is  not  in  the  field,  these  instruments  are  awkward  and  unwieldy  in  over- 
coming the  difficulty ;  indeed,  in  many  cases,  the  speculum  must  be  with- 


Neugebauer's  speculum. 


96 


MEANS    OF    DIAGNOSIS. 


drawn  and  reintroduced  to  accomplish  the  result.  They  have  one  great 
advantage  over  the  cylindrical  specula,  namely,  their  introduction  is  at- 
tended by  much  less  pain.  Should  the  case  be  one  of  a  multipara,  a 
cylinder  may  be  introduced  without  pain,  but  in  a  nullipara,  or  virgin, 
this  is  often  caused. 

Like  the  cylindrical,  the  valvular  specula  in  general  use  do  not  as  a 
rule  admit  of  probing  the  uterus  and  making  applications  to  the  fundus. 

I  do  not  deny  that  in  some  cases  it  is  possible, 
nor  that  by  perseverance  a  skilful  operator  may 
succeed  in  effecting  these  objects  in  many  in- 
stances, but  it  is  usually  so  difficult  that  the 
general  practitioner  will  not  find  such  specula 
available  for  these  ends. 

Fig.  15. 


Fio.  14. 


IEMANN  &CC 

Sims"s  depressor. 

Sims's  speculum,  Fig.  14,  which  is  in  reality 
a  bivalve,  obviates  all  these  difficulties  in  the 
most  complete  and  satisfactory  manner.  In 
exposing  the  uterus  it  develops  a  principle  not 
brought  into  action  by  any  other  variety,  the 
Sims's  speculum.  dilatation  of  the  vaginal  canal  by  air,  which 

enters  on  account  of  the  position  of  the  patient 
and  gravitation  of  the  pelvic  and  abdominal  viscera.  I  have  stated  that 
this  instrument  is  a  bivalve  speculum  ;  the  upper  valve  is  constituted  by 
the  blade  of  the  speculum  itself,  and  the  lower  by  the  depressor,  represented 
in  Fig.  15,  which  acts  upon  the  anterior  wall. 

The  facility  which  Sims's  instrument  gives  for  exploration  and  treat- 
ment is  very  great,  so  great,  I  think,  that  the  practitioner  devoting  him- 
self to  gynecology  who  does  not  avail  himself  of  it,  loses  as  great  an  ad- 
vantage as  the  auscultator  would  forego  in  not  bringing  to  his  aid  the 
double  stethoscope  of  Camraan.  But  unfortunately  this  instrument  pre- 
sents such  disadvantages  that  it  can  never  come  into  general  use.  In  the 
hands  of  those  attending  a  sufficient  number  of  cases  of  uterine  disease  to 
give  them  skill  in  manipulation  and  opportunity  for  thoroughly  familiariz- 
ing themselves  with  it,  it  will  always  fill  a  large  place,  but  in  general 
practice  it  will  not  do  so.  It  cannot  be  employed  without  an  assistant, 
and  not  only  so,  a  skilled  assistant  is  necessary  for  it  to  be  of  real  value. 
This  fact  has  incited  many  to  alter  Dr.  Sims's  original  model  so  as  to 
combine  its  advantages  in  instruments  free  from  the  objections  which  have 
been  mentioned.     A  few  of  these  I  lay  before  the  reader. 


THE    SPECULUM, 


97 


Fig.  16. 


"When  the  posterior  vaginal  wall  is  lifted  by  Sims's  speculum,  the  an- 
terior must  be  depressed  by  an  instrument  held  in  the  other  hand.  Thus 
both  hands  are  occupied,  and  the  operator  is  bereft  of  power  to  proceed. 
The  object  of  the  alteration  is 
to  liberate  one  hand  in  order 
that  the  further  steps  of  the 
examination  may  be  proceeded 
with. 

Dr.  Nott's  speculum  (Fig. 
10)  does  this  by  depressing  the 
anterior  vaginal  wall  by  two 
short  arms.  These  at  the  same 
time  keep  the  blade  of  the 
speculum  itself  in  {dace,  and 
thus  either  one  or  both  hands 
are  free  for  making  applica- 
tions to  the  uterus,  probing  its 
cavity,  or  whatever  else  may 
be  required. 

The  speculum  of  Dr.  J.  B.  Hunter  (Fig.  17)  is  simply  Sims's  speculum, 
with  its  blades  bent  inwards  so  as  to  enable  the  examiner  to  fix  it  in  a 
support  which  is  attached  to  the  table  and  acts  as  a  mechanical  assistant. 
The  speculum  being  thus  fixed  keeps  its  position  perfectly,  and  the  exam- 
iner with  both  hands  free,  proceeds  in  his  investigation,  employing  the 
depressor  as  when  an  assistant  aids  him.  To  make  this  arrangement 
effectual  some  practice  is  necessary,  but  with  that  it  will  prove  an  excel- 
lent one. 


Nott's  speculum,  closed. 


Fig.  17. 


Fig.  18. 


Hunter's  speculum. 


Thomas's  modification  of  Sims's  speculum. 


The  instrument  represented  in  Fig.  18  clasps  the  sacrum ;  one  blade,  a, 
the  speculum  itself,  being  placed  within  the  vagina,  and  the  other,  on  the 
outer  surface  of  the  sacrum.     Their  approximation  by  the  left  hand  ele- 

7 


98  MEANS    OF    DIAGNOSIS. 

vates  the  posterior  vaginal  wall,  and  the  handle  is  held  by  one  hand.  The 
anterior  wall  is  then  depressed  by  the  depressor,  and  thus  one  hand  is  left 
free.  This  instrument  appears  complicated  in  a  diagram,  but  in  reality  it 
is  by  no  means  so.  For  a  long  time  I  employed  it  without  the  sacral 
piece.  Some  even  now  prefer  it  thus,  though  the  fatigue  which  it  causes 
to  the  left  arm  in  lifting  the  posterior  vaginal  wall  and  perineum,  consti- 
tutes an  objection  to  it. 

Method  of  Introducing  Valvular  and  Cylindrical  Specula The  patient 

being  placed  in  position  on  the  back,  as  already  explained,  and  the  specu- 
lum, probe,  and  whatever  other  instruments  are  to  be  employed,  laid  in  a 
basin  of  warm  water  at  the  bedside,  the  physician  seats  himself  in  a  chair, 
or  if  a  low  bed  be  used  instead  of  a  table,  kneels  or  sits  upon  a  stool.  The 
finger,  having  been  thoroughly  lubricated  with  soap  or  carbolized  vaseline, 
is  passed  up,  and  the  location  of  the  cervix  ascertained.  The  speculum, 
similarly  lubricated,  is  then  passed  in  this  way;  if  the  cylindrical  instrument 
be  used,  the  perineifm  is  depressed  by  its  tip,  and  it  is  very  slowly  and  gently 
inserted  and  carried  to  the  cervix ;  should  one  of  the  valvular  varieties  be 
employed,  it  is  inserted  closed,  and  expanded  after  reaching  the  cervix. 

Introduction  of  Sims' s  Speculum  and  its  Varieties In  this  method  of 

examination  the  element  which  commands  success  is  not  the  use  of  the 
instrument,  but  the  position  of  the  patient.  If  the  position  recommended 
by  Sims  be  attained,  exposure  of  the  cervix  will  be  easy ;  if  a  similar  but 
not  identical  attitude  be  substituted,  the  examination  will  prove  entirely 
unsatisfactory. 

The  object  of  the  position  is  to  allow  the  abdominal  viscera  and  walls  to 
gravitate,  so  as  to  draw  the  anterior  wall  of  the  vagina  forwards,  in  a 
direction  opposite  to  that  impressed  upon  the  posterior  wall  by  the  specu- 
lum. To  accomplish  this  the  patient  must  be  not  on  her  back,  nor  on  her 
side,  but  in  a  position  between  the  two.  This  is  well  represented  in 
Fig.  19.  The  left  arm  must  be  drawn  behind  the  patient  so  as  to  let  her 
rest  on  the  left  side  of  the  chest,  and  the  right  leg  be  so  flexed  as  to  let 
the  right  knee  lie  just  above  the  left. 

When  the  patient  is  arranged,  the  correctness  of  the  posture  may  be 
tested  by  noting  that  the  lower  trochanter  is  not  just  opposite  the  upper, 
but  nearer  to  the  examiner  by  two  or  three  inches.  I  am  thus  particular  in 
describing  this  position,  first,  because  it  is  difficult  for  one  unaccustomed  to 
its  employment  to  place  his  patient  properly  in  it;  and,  second,  because 
upon  its  perfect  attainment  depends  the  successful  use  of  Sims's  speculum. 
The  patient  being  in  position,  the  speculum  is  introduced,  the  posterior 
vaginal  wall  elevated  by  it  and  the  anterior  depressed  by  the  depressor, 
Fig.  15,  held  in  the  other  hand,  or  by  the  mechanical  depressor  represented 
in  Fie.  1*. 


THE    SPECULUM. 


99 


One  reason  why  the  great  advantages  of  Sims's  speculum  are  not  more 
generally  recognized  and  acknowledged  is  unquestionably  to  be  found  in 


Fig.  19. 


Nurse  holding  Sims's  speculum.     (Sims.) 


the  fact  that  the  patient  is  not  properly  arranged  before  its  introduction. 
To  impress  this  fact  and  to  show  how  faulty  the  arrangement  of  the  *pa- 


Fig.  20. 


Position  of  woman  in  examining  with  Sims's  speculum.     (Leblond.) 


tient  may  be,  I  introduce  a  diagram  from  a  recent  and  very  excellent 
French  work  upon  gynecological  surgery. 

No    diagram    could    better   represent   how  the  woman    should  not  be 
placed  than  this. 


100  MEANS    OF    DIAGNOSIS. 

The  Uterine  Sound This  valuable  diagnostic  means,  although  to  a 

certain  extent  known  in  ancient  times,  was  more  recently  recommended 
in  1828  by  Samuel  Lair.1  It  was  not  however  adopted  upon  his  recom- 
mendation, and  it  was  not  until  about  the  year  1843  that  it  was  generally 
accepted.  At  this  time  its  claims  were  simultaneously  urged  by  Simpson 
of  Edinburgh,  Huguier  of  Paris,  and  Kiwisch  of  Prague,  working  with- 
out concert.  It  matters  little  to  which  of  them  belongs  the  credit  of 
having  been  the  first  to  conceive  the  idea  of  the  regeneration,  to  Simpson 
certainly  belongs  that  of  having  forced  it  upon  the  attention  of  the  profes- 
sion and  established  its  value  by  clinical  evidence. 

The  instruments  in  general  use  are  those  of  Simpson,  Valleix,  Huguier, 
and  Kiwisch,  which  resemble  each  other  closely  in  principle,  each  consist- 
ing of  a  stiff  metal  rod  divided  into  quarter  inches  and  bent  so  as  to  pass 
in  the  axis  of  the  healthy  uterus.  The  method  of  their  introduction  is 
this :  the  index  finger  of  one  hand  being  introduced  into  the  vagina  and 
placed  against  the  cervix,  the  sound  is  by  the  other  slid  upon  its  palmar 
surface  to  the  os,  passed  into  it,  and  by  depression  of  the  handle  gently 
advanced  to  the  fundus.  If  the  uterus  be  in  its  normal  position,  and  the 
sound  be  used  by  a  skilful  hand,  the  operation  is  not  difficult.  But  it  is 
not  the  healthy  uterus  which  we  are  generally  called  upon  to  explore.  If 
the  organ  be  displaced,  the  difficulties  and  dangers  attending  the  employ- 
ment of  the  sound  are  considerable,  as  may  be  judged  of  from  the  following 
quotations  : — 

BecquereP  says:  "  But  its  employment  is  attended  with  such  difficulty 
that  it  requires  all  the  skill  of  an  adroit  and  experienced  practitioner,  and 
we  dread  seeing  it  popularized  among  young  physicians  of  little  skill  and 
experience."  Nonat3  declares  that,  "  on  account  of  the  accidents  which 
sounding  may  excite,  it  should  only  be  resorted  to  with  great  caution  and 
in  those  cases  where  its  necessity  is  clearly  shown."  Scanzoni4  candidly 
acknowledges  that,  "in  the  first  place,  the  uterine  sound  is  by  no  means 
so  harmless  as  has  been  asserted,"  and  then  goes  on  to  sum  up  the  evils 
which  may  result  from  it.  But  I  will  not  quote  more ;  this  suffices  to 
show  how  the  difficulties  and  dangers  to  which  I  have  alluded  are  regarded 
by  some  of  the  best  authorities  of  our  day. 

The  facts  which  may  be  ascertained  by  the  sound  are  these : — 

1.  The  capacity  of  the  uterus. 

2.  The  existence  of  growths  within  it. 

3.  Deviations  of  the  course  of  its  canal. 

4.  Differentiation  of  displacements  from  uterine  tumors. 

5.  The  mobility  of  the  uterus. 

1  Samuel  Lair,  "  Nouvelle  methode  de  traitement  des  ulceres,  ulcerations  et  en- 
gorgement de  l'uterus,"  1828. 

2  Maladies  de  l'utdrus.  3  Maladies  de  l'uterus. 
4  Diseases  of  Females,  Am.  ed. 


THE    UTERINE    SOUND. 


101 


The  great  importance  of  these  facts  with  reference  to  diagnosis  is  evi- 
dent, and  one  would  suppose  that  an  instrument  revealing  so  much  would 
be  universally  employed.  Such,  however,  is  not  by  any  means  the  case. 
By  adepts  it  is  commonly  resorted  to,  but  in  general  practice  will  be  found 
many,  indeed  a  majority,  who  do  not  employ  it  from  fear  of  its  results, 
the  difficulty  of  its  introduction,  and  uncertainty  as  to  its  revelations. 

Dr.  Sims  has,  however,  furnished  us  with  a  new  instrument  and  method 
for  probing  the  uterus,  which  acts  upon  an  essentially  different  principle 
from    that  formerly  employed, 

and  makes  the  investigation  so  Fig-  21. 

simple  and  void  of  danger,  that 
I  strongly  recommend  its  adop- 
tion. 

Fig.  21  represents  the  sounds 
of  Simpson  and  Sims,  for  the 
purpose  of  contrasting  them. 
The  first  is  a  strong,  unyield- 
ing staff,  composed  of  German 
silver,  and  as  large  as  a  No.  3 
catheter. 

The  second  is  not  a  sound, 
but  a  probe,  only  a  little  larger 
than  the  ordinary  surgical 
probe,  composed  of  pure  silver 
or  copper,  and  perfectly  pliable. 
Mode  of  Probing  the  Uterus. 
— While  the  woman  lies  on  her 
back,  the  examiner,  by  vaginal 
touch,  carefully  ascertains  the 
position  of  the  uterus,  by  pass- 
ing his  finger,  first  into  the 
fornix  vaginas,  over  its  poste- 
rior face,  and  then  along  the 
base  of  the  bladder,  over  its 
anterior  wall.  This  gives  him 
a  definite  idea  of  the  direction  of  the  canal  along  which  he  is  to  pass  his 
probe,  and  without  it  he  should  never  essay  the  procedure.  The  specu- 
lum is  then  introduced,  the  patient  being  turned  on  the  left  side.  The 
examiner  then  takes  th.3  probe,  and  with  his  fingers  gives  it  the  exact 
curve  which  he  supposes  the  uterine  canal  to  have,  and  gently  endeavors 
to  pass  it  in.  Should  he  fail,  he  withdraws  the  instrument,  alters  the 
curve  slightly,  and  makes  other  attempts  until  he  succeeds,  which  will 
be  very  soon  if  he  has  used  this  method  so  often  as  to  have  given  himself 
experience.     Every  effort  at  introduction  is  made  as  cautiously  as  if  the 


Sounds  of  Simpson  and  Sims  compared. 


102  MEANS    OF    DIAGNOSIS. 

probe  were  passing  into  the  larynx  instead  of  the  womb,  and  no  force 
whatever  is  exerted.  Success  is  attained  by  properly  curving  the  probe, 
and  by  that  alone.  Sometimes  the  inflection  given  to  it  must  be  the  arc 
of  a  small  circle  ;  at  others  a  sharp  angle  ;  sometimes  the  instrument  is 
left  perfectly  straight ;  in  fact  every  variety  of  direction  may  be  given  it. 
In  a  certain  set  of  rare  cases,  even  a  spiral  twist  is  required. 

Thus  employed,  the  uterine  probe  becomes  a  means  of  verifying  a  diag- 
nosis which  has  been  made  by  touch,  and  is  certainly  safe,  easy  of  intro- 
duction, and  painless.  It  may  be  used  in  all  cases  except  pregnancy, 
doing  no  injury  even  in  endometritis,  so  gentle  is  its  entrance  into  the 
inflamed  cavity. 

No  one  can  dispute  the  fact  that  having  been  passed  it  performs  the 
chief  functions  of  the  sound,  proclaiming  the  course,  length,  and  capacity 
of  the  uterine  canal. 

As  the  practitioner  grows  in  skill  in  the  practice  of  conjoined  manipu- 
lation, that  most  valuable  and  reliable  of  all  his  means  of  diagnosis,  he  will 
less  and  less  frequently  find  a  resort  to  the  sound  or  probe  necessary.  In 
the  vast  majority  of  his  cases  he  will  by  that  means  so  clearly  determine 
all  that  the  sound  or  probe  could  reveal,  that  he  will  feel  satisfied  without 
further  investigation. 

Fig.  22. 


Jenks's  elastic  sound. 

Some  cases  of  enlarged  uteri,  with  or  without  the  presence  of  submucous 
fibroids,  require  the  use  of  an  elastic  sound  for  their  full  exploration.  For 
this  purpose  sounds  of  gum  elastic  and  whalebone  have  been  employed. 
A  very  excellent  elastic  sound  of  metal  has  been  devised  by  Dr.  E.  W. 
Jenks,  of  Chicago,  and  an  exceedingly  ingenious  one  by  Jenison,  which 
will  be  elsewhere  represented. 

Tents Before  the  time  of  Recamier,  the  cavity  of  the  uterus  was  a 

space  entirely  closed  to  investigation  and  local  therapeutics,  unless  the  os 
were  greatly  dilated  by  disease.  He  not  only  aspired  to  an  accurate 
knowledge  of  its  affections,  but  boldly  applied  his  remedies  directly  to  the 
diseased  surface  ;  and,  in  cases  of  intra-uterine  granulations,  scraped  off* 
the  diseased  mucous  coat  with  the  curette.  Even  to  him,  however,  the 
diagnosis  of  diseases  within  the  cavity,  when  the  os  was  closed,  was  an 
impossibility,  and  for  the  means  of  combating  this  difficulty  we  are  again 
indebted  to  Dr.  Simpson,  who,  in  1814,  placed  the  use  of  sponge-tents 
among  the  most  important  of  our  resources  for  diagnosis. 


TENTS.  103 

The  object  for  which  they  are  employed  is  the  dilatation  of  the  cervical 
canal,  in  order  that  the  cavity  of  the  body  may  be  examined  by  touch  or 
sight,  and  that  treatment  may  be  applied  in  cases  of  polypi,  granulations, 
fibrous  tumors,  hydatids,  removal  of  the  products  of  conception,  etc. 

Various  substances  have  been  recommended  for  the  manufacture  of 
tents,  only  two  of  which  have  thus  far  come  into  general  use,  compressed 
sponge  and  the  laminaria  digitata,  or  sea-tangle. 

The  practitioner  should  no  more  think  of  preparing  his  own  sponge- 
tents  than  his  extracts  or  tinctures.  They  are  now  made  by  those  who 
possess  much  more  skill  and  experience  than  himself,  and  by  procuring 
them  from  these  manufacturers  the  interests  of  both  himself  and  his  patient 
will  be  subserved.     They  should  be  steeped  in  a  solution  of  carbolic  acid 

Fig.  23. 


A  sponge-tent,  with  thread  passing  through  it.1 


as  an  antiseptic,  and  may  be  medicated  with  iodine,  zinc,  copper,  or  other 
substances.  The  cord  attached  to  a  tent  should  always  pass  through  it, 
and  out  at  its  upper  extremity.  A  neglect  of  this  simple  precaution  has 
repeatedly  allowed  a  tent  to  break  upon  its  removal,  and  one-half  to  remain 
in  the  cavity  of  the  body  of  the  uterus. 

Preparation  of  Sea-Tangle  Tents — In  18G2,2Dr.  Sloan,  of  Ayr,  Scot- 
land, first  recommended  the  use  of  this  substance  for  dilating  the  cervix 
uteri.  The  laminaria  is  an  aquatic  plant  found  upon  various  parts  of  the 
Atlantic  coast  of  Europe  and  America.  That  found  in  the  Bay  of  Fundy, 
I  am  informed  by  Messrs.  Tiemann  &  Co.,  is  far  superior  to  any  other 
with  which  they  have  experimented.  This  plant,  when  saturated  with 
moisture,  swells  to  three  times  the  bulk  which  it  has  when  thoroughly 
dried.  In  its  moist  state  a  long  piece  of  it  is  perforated  at  both  extremi- 
ties, in  order  that  it  may  be  hung  up  and  allowed  to  dry,  a  weight  being 
attached  to  the  lower  end  so  as  to  stretch  it  and  make  it  straight.  "When 
dry,  this  is  cut  into  pieces  from  two  to  two  and  a  half  inches  long  and  made 

1  The  extremities  of  this  thread  should  of  course  he  tied  together. 

2  Glasgow  Med.  Journ.,  Oct.  1SG2. 


104  MEANS    OF    DIAGNOSIS. 

perfectly  smooth  and  round  by  a  knife,  a  piece  of  glass,  or  sand-paper. 
Tiemann  &  Co.  prepare  them  very  beautifully  by  turning  in  a  lathe. 

Dr.  Greenhalgh,  of  London,  has  improved  these  tents  by  having  them 
perforated  from  one  extremity  to  the  other,  so  as  to  make  them  tubular 

instead  of  solid.     Thus  prepared 
Fig.  24.  they    will    dilate     much    more 

jgggf^^^^^waijiiigijjMBMMiigjpgv      rapidly  and  completely.     One  of 
\T^~  Dr.  Greenhalgh's  tents  is  repro- 

ve ^"X  sented  in  Fig.  24. 

n.      \_^^  The  advantages  of  these  tents 

x^       J*-~  "V"*7-— ~  over  those  made  of  sponge  con- 

a  sea-tanSie  tent.  sist  in   their  creating,  no   fetor, 

and  presenting  no  animal  matter 
for  absorption.  Their  disadvantages  are  their  requiring  a  longer  time  for 
expansion,  their  being  kept  in  the  cervix  with  greater  difficulty,  and  offer- 
ing a  harder  substance  to  the  walls  of  the  cavity  of  the  uterus. 

The  late  Dr.  Nott,  who  experimented  extensively  with  them,  arrived 
at  conclusions  very  much  in  their  favor,  as  will  be  seen  from  an  examina- 
tion of  his  deductions  which  I  here  place  before  the  reader. 

"  1st.  Where  moderate  dilatation  is  required,  the  laminaria  is  preferable 
to  the  sponge-tents. 

"  2d.  If  placed  in  warm  water,  just  before  introduction,  for  a  few  minutes, 
they  become  flexible,  coated  with  mucilage,  are  easily  curved  to  suit  the 
cervical  canal,  and  may  bo  inserted  with  the  utmost  facility. 

"  3d.  From  their  smoothness  and  softness  they  are  removed  without 
force,  and  produce  no  abrasion  or  irritation. 

"  4th.  They  may  be  medicated  with  morphia,  iodine,  or  anything  soluble 
in  water,  but  do  not  absorb  alcoholic  solutions  or  glycerine.  After  being 
so  charged,  they  may  be  dried  and  kept  for  use  an  indefinite  time. 

"  5th.  They  do  not  become  putrid,  and  therefore  poisonous,  as  do  sponge- 
tents,  and  may  therefore  be  retained  twenty-four  hours  or  more  with  im- 
punity. 

"Oth.  The  black,  ovoid  laminaria,  from  the  Bay  of  Fundy,  is  much  pre- 
ferable to  the  other  varieties  yet  brought  to  our  markets,  and  free  from  the 
objections  made  to  laminaria  by  some  writers. 

"  7th.  The  laminaria  will  be  found  of  great  benefit  in  obstructive  dys- 
menorrhea, if  introduced  a  few  days  before  the  menstrual  period,  and  also 
in  cases  of  uterine  catarrh  connected  with  contracted  cervix  ;  they  prepaid 
the  way  well,  too,  for  all  intra-uterinc  medication.  In  either  case,  if 
softened  in  hot  water  before  introduction,  they  rarely  produce  any  pain  or 
irritation. 

"  8th.  It  is  better  to  insert  several  small  tents  than  one  large  one,  as  the 
small  ones  expand  more  rapidly  than  the  large  ones." 

The  bust  point  here  mentioned  is  one  of  great  importance  in  their  use, 
and  for  its  recognition  we  are  indebted  to  Dr.  Kidd,  of  Dublin.     He  thus 


TENTS, 


105 


speaks  of  it.  "  When  the  uterine  tissues  are  relaxed  by  hemorrhage,  a  fine 
tent  can  be  passed  at  once  through  the  whole  length  of  the  cervix  and  on 
to  the  fundus,  and  by  a  little  care  a  number  of  fine  tents  can  be  packed 
alongside  of  one  another  in  the  canal,  when  a  single  large  one,  though  not 
nearly  of  the  size  of  the  bundle  so  formed,  could  not  be  passed  at  all.  The 
first  tent  introduced  serves  as  a  guide  to  the  others,  and  when  they  absorb 
fluid  and  swell  out,  they  not  only  dilate  the  os  internum  as  much  as  the 
os  externum,  but  also  the  cavity  of  the  uterus  itself."1 

Of  late  Dr.  G.  E.  Sussdorff,  of  this  city,  has  recommended  the  use  of 
tents  made  of  wood  of  the  tupelo  or  nyssa,  a  tree  growing  throughout  the 
Southern  States.  Upon  his  recommendation  I  commenced  the  use  of  these 
tents,  and  have  been  so  much  pleased  with  them  as  to  have  for  the  past 
year  employed  them  very  generally.  They  do  not  upon  absorption  of 
moisture  expand  as  much  as  sponge,  but  they  make  up  for  this  defect  by 

Fig.  25. 


A  tupelo  tent  before  and  after  introduction  and  expansion. 

unyieldingly  maintaining  their  increased  size  after  expansion  which  sponge 
fails  to  do.  Fig.  25  represents  one  of  these  tents  before  introduction  by 
myself,  in  a  case  of  a  patient  suffering  from  a  submucous  fibroid,  and  the 
same  upon  removal  at  the  end  of  twenty-four  hours.  The  figures  are  of 
natural  size. 

The  tupelo  tent  has,  I  feel  sure,  a  brilliant  future  before  it.  While  it 
will  not  entirely  supersede  sponge,  it  will  in  a  great  many  cases  replace  it. 

Mode  of  introducing  Tents. — If  the  uterus  be  low  in  the  pelvis  and  its 


i  Dublin  Quarterly  Journ.,  Feb.  18C9. 


106 


MEANS    OF    DIAGNOSIS. 


neck  dilated,  a  tent  may  be  held  in  the  bite  of  any  pair  of  uterine  dressing- 
forceps  and  slipped  in  without  the  speculum,  the  woman  lying  on  the  back. 
In  ordinary  cases  they  should  be  introduced  through  the  short  cylindrical, 
or  one  of  the  varieties  of  Sims's  speculum.  The  introduction  is  most 
easily  accomplished  with  the  last  in  all  cases,  and  in  some  it  can  only  be 

Fig.  26. 


Tenaculum  for  fixing  the  uterus. 

effected  with  it.  Before  the  introduction  of  the  tent  the  vagina  should  be 
syringed  out  with  carbolized  water,  and  the  tent,  having  been  lubricated 
with  carbolized  vaseline  or  gelatum  petrolei  and  grasped  by  a  pair  of  for- 
ceps, is  directed  in  coincidence  with  the  uterine  axis  as  ascertained  by 
the  probe,  and  gently  pushed  through  the  cervix,  as  represented  in 
Fig.  27. 

Fig.  27. 


Introduction  of  a  tent.     (Sims.) 

After  this  the  vagina  should  be  syringed  out  with  carbolized  water,  a 
mass  of  carbolized  cotton  packed  against  the  cervix  so  as  to  exclude  atmo- 
spheric air  and  keep  the  tent  in  place,  and  the  woman  be  directed  to 
remain  in  bed  until  it  is  removed. 

Its  removal  is  accomplished,  through  the  speculum,  after  removal  of  the 
cotton  and  syringing  with  carbolized  water,  in  from  twelve  to  twenty-four 
hours,  with  the  same  forceps  by  which  it  was  introduced,  or  by  traction 
upon  the  thread  attached  to  it,  the  patient  lying  upon  the  back. 

Dangers. — There  is  always  danger  in 'dilating  the  cervix  by  tents, 
though  it  is  by  no  means  so  great  as  to  make  one  hesitate  in  employing 
them,  for  the  cases  which  demand  them  are  often  urgent  ones,  and  they 


TENTS.  107 

serve  a  purpose  not  attainable  by  any  other  means.  It  is  much  to  be 
regretted  that  practitioners  have  not  shown  more  alacrity  in  publishing 
unfortunate  results  from  the  use  of  this  method  of  exploration  and  treat- 
ment. Had  all  the  fatal  cases  which  have  resulted  from  accidents  due  to 
tents  been  faithfully  recorded,  the  list  would  now  be  a  long  one,  and  it 
would  be  greatly  lengthened  by  a  record  of  all  the  instances  in  which 
tedious,  exhausting,  and  dangerous  disease  has  thus  been  excited.  It 
may  then  be  asked  whether  it  is  right  to  recommend  a  method  accompa- 
nied by  so  much  danger.  The  same  line  of  argument  applies  to  this 
question,  which  does  to  so  many  similar  ones  in  medicine.  Great  dangers 
attend  the  use  of  anaesthetics,  of  narcotics,  and  of  other  means  which  are 
in  daily  use,  but  the  proportion  of  accidents  occurring  from  their  use  is 
small  although  the  aggregate  is  large;  and  the  good  which  they  effect  is 
so  great  that  their  evils  must  be  condoned. 

In  my  own  practice  I  have  met  with  four  fatal  cases  resulting  from  the 
use  of  tents.  In  one  they  were  employed  to  remove  a  foetal  shell  which 
had  been  retained  for  two  months  and  was  destroying  the  patient's  life 
by  septicaemia;  in  the  others  the  cervix  was  being  dilated  for  the  removal 
of  fibrous  polypi,  the  hemorrhage  from  which  had  greatly  exhausted  the 
patients.  One  of  these  women  died  from  tetanus,  one  from  peritonitis, 
one  from  an  overwhelming  and  sudden  attack  of  septicaemia,  and  one  from 
sloughing  of  a  fibroid  and  chronic  septicaemia. 

Some  time  ago  I  was  called  in  consultation  to  the  bedside  of  a  lady 
who  was  dying  of  general  peritonitis,  which  had  arisen  one  week  after  the 
removal  of  a  sponge-tent  employed  for  dysmenorrhea  by  her  physician, 
who  was  a  most  careful  and  competent  practitioner.  Dr.  Braxton  Hicks 
says,  "I  have  seen  a  case  end  fatally  where  there  had  been  dilatation  a 
wreek  previous;  mental  shock  suddenly  lighting  up  the  inflammation  and 
extending  it  to  the  peritoneum."  Besides  these  cases  I  have  seen,  as  every 
other  gynecologist  has  who  has  employed  this  means  to  any  extent,  a  num- 
ber in  which  the  following  affections  have  been  excited  by  tents :  pelvic 
peritonitis,  peri-uterine  cellulitis,  septicaemia,  endometritis,  and  hematocele. 

This  is  the  record  of  my  own  practice,  and  my  observation  of  that  of 
many  of  my  friends  whose  results  I  have  had  an  opportunity  of  seeing  ex- 
actly agrees  with  it.  Let  it  be  remembered  that  many  of  the  operations  of 
gynecology  are  performed  after  dilatation  of  the  cervix  by  tents.  A  fatal 
result  ensuing  is  commonly  attributed  to  the  operation.  With  my  experi- 
ence I  cannot  doubt  that  the  preparatory  dilatation  is  accountable  for  it 
in  many  cases. 

In  view  of  the  great  suddenness  with  which  the  dangerous  symptoms 
which  follow  the  use  of  tents  develop  themselves,  I  confess  myself  greatly 
at  a  loss  to  account  for  the  method  by  which  they  establish  the  morbid 
train.  My  impression  is  that  the  tent  establishes  a  lymphangitis  or 
angeioleucitis  in  the  abundant  network  of  uterine  lymphatics,  and  that 


108  MEANS    OF    DIAGNOSIS. 

from  this  source,  as  in  cases  of  dissecting  wounds,  a  rapid  advance  of 
inflammation  takes  place  to  neighboring  parts.  In  this  way  the  perito- 
neum and  pelvic  areolar  tissue  are  reached ;  in  this  way  septicaemia  devel- 
ops itself.  How  else  could  these  parts  become  affected  in  the  course  of 
twelve  or  twenty-four  hours?  Even  if  a  septic  endometritis  were  estab- 
lished which  reached  the  peritoneum  through  the  Fallopian  tubes,  perito- 
nitis would  be  the  invariable  result,  which  is  not  the  case,  and  the  devel- 
opment of  this  would  probably  be  less  rapid. 

This  subject  is  one  of  so  great  importance  that  I  deem  it  best  before 
leaving  it  to  enumerate  certain  rules  which  should  always  govern  the 
practitioner  who  resorts  to  this  valuable,  but  at  the  same  time  unquestion- 
ably hazardous,  method  of  diagnosis  and  treatment. 

1st.  In  the  introduction  of  a  tent  no  force  whatever  should  be  employed. 
Should  that  first  essayed  not  pass  the  os  internum  easily,  it  should  be  at 
once  withdrawn,  and  either  bent  so  as  to  follow  more  accurately  the  course 
of  the  cervical  canal  as  ascertained  by  the  probe,  or  exchanged  for  a 
smaller  tent. 

2d.  A  tent  should  never,  under  any  circumstances,  be  introduced  at 
the  physician's  office  and  the  patient  allowed  to  go  home  with  it  in  utero. 
Such  practice  is  hazardous  in  the  extreme.  Even  when  introduced  at  the 
patient's  home  she  should  at  once  be  confined  to  the  recumbent  posture 
and  kept  perfectly  quiet.  The  tent  should  be  covered  with  carbolized 
vaseline. 

3d.  The  practitioner  should  always  investigate  as  to  the  previous  exist- 
ence of  chronic  pelvic  peritonitis  or  cellulitis,  two  of  the  most  common  of 
the  diseases  of  women.  Should  they  have  existed,  tents  should  be  care- 
fully avoided.  In  most  of  the  instances  in  which  I  have  seen  dangerous 
results  follow  their  use,  one  of  these  conditions  had  previously  existed  and 
been  excited  into  activity  by  them. 

4th.  A  tent  should  never  be  allowed  to  remain  in  the  uterus  more  than 
twenty-four  hours,  and  if  it  be  compatible  with  the  accomplishment  of  the 
desired  result,  it  should  be  removed  in  twelve  hours. 

5th.  Just  before  and  just  after  removal  of  a  tent,  the  vagina  should  be 
washed  out  with  an  antiseptic  fluid,  and  if  any  pain,  chilliness,  or  discom- 
fort follow  the  removal,  opium  should  be  freely  administered  and  perfect 
quietude  enjoined. 

Gth.  After  removal  of  a  tent,  the  patient  should  be  kept  in  bed  for  at 
least  twenty-four  hours,  and  never  allowed  to  travel  before  the  expiration 
of  four  or  five  days. 

I  am  fully  aware  that  these  precautions  will  be  incredulously  received 
by  those  practitioners  who  have  habitually,  and  with  impunity,  inserted 
tents  at  their  offices,  and  sent  the  patients  home  with  directions  to  remove 
them,  by  means  of  the  cord,  on  the  next  day.  But  it  is  the  duty  of  every 
conscientious  man  to  give  weight  to  the  experience  of  others.     If  it  were 


THE    ASPIRATOR.  109 

essential  for  every  practitioner  to  lose  one  patient  from  this  or  any  kindred 
cause  before  regarding  it  as  really  dangerous,  the  number  of  fatal  cases 
would  necessarily  grow  very  large. 

The  Exploring  Needle — By  means  of  a  long,  delicate  needle,  or 
very  narrow  tube,  constituting  a  canula  for  a  trocar  the  size  of  a  small 
knitting-needle,  the  contents  and  characters  of  tumors  in  the  pelvis  may 
be  ascertained.  These  instruments  are  not  employed  in  treating  cysts, 
but  are  required  only  to  remove  sufficient  fluid  to  announce  the  character 
of  the  contents  of  the  tumor.  Sometimes  a  tumor,  supposed  to  be  solid 
and  irremediable,  is  thus  proved  to  be  amenable  to  treatment. 

The  Aspirator To   whom  belongs    the    credit  of   originating  this 

method  of  evacuating  the  fluid  contents  of  tumors  or  cavities  I  am  unable 
to  say.  M.  Courty  alludes  to  it  as  a  method  of  emptying  ovarian  cysts  in 
use  ten  years  before  the  appearance  of  his  work,  and  mentions  the  instru- 
ments employed  for  that  purpose  by  Buys,  Monro,  Guerin,  and  Boinet. 
To  M.  Dieulafoy,  of  Paris,  certainly  belongs  the  credit  of  systematizing 
and  popularizing  it  to  such  an  extent  that  it  must  be  looked  upon  as  a 
great  resource,  not  only  for  diagnosis,  but  treatment  of  many  of  the  morbid 
states  with  which  the  gynecologist  is  called  to  deal. 

This  method  consists  in  the  introduction  of  very  slender,  long  needles 
perforated  by  a  capillary  tube,  into  tumors  in  regard  to  the  characters  of 

Fig.  28. 


Dieulafoy's  aspirator. 

which  it  is  desired  to  decide  ;  connecting  these  by  gutta-percha  tubes  with 
a  glass  cylinder  in  which  a  powerful  piston  plays  very  accurately;  and 
creating  a  vacuum  in  this  by  drawing  the  piston  upwards.  Powerful  suc- 
tion is  thus  exerted  upon  the  material  in  the  cavity  penetrated  by  the 
needle,  and,  if  it  consist  of  fluid  not  too  tenacious  to  flow  through  so  small 
a  needle,  it  passes  through  the  tube  and  enters  the  cylinder.  Fig.  28  ex- 
hibits the  most  recent  modification  of  Dieulafoy's  aspirator.     Such  instru- 


110  MEANS    OF    DIAGNOSIS. 

merits,  very  perfectly  constructed,  can  now  be  obtained  of  tbe  instrument 
makers  of  this  city. 

One  great  advantage  possessed  by  this  instrument  consists  in  the  fact 
that  the  needles  are  so  delicate  that  the  intestines,  the  bladder,  solid  tu- 
mors, or  even  important  secernent  organs  may  be  penetrated  without  great 
danger.  The  sac  imprisoned  in  intestinal  hernia,  the  large  intestine  dis- 
tended by  gases,  the  bladder  threatened  with  rupture  by  impassable  stric- 
ture, have  all  been  tapped  by  it  with  impunity. 

Before  passing  the  needle  into  the  tissue  of  a  tumor  or  other  growth  it 
should  always  be  immersed  in  hot  carbolized  water  and  thoroughly 
cleansed. 

Should  the  operator  not  have  this  instrument  at  his  disposal,  the  same 
principle  may  be  applied  to  diagnosis  by  the  use  of  the  ordinary  hypoder- 
mic syringe,  as  suggested  by  Dr.  II.  F.  Walker,  and  sufficient  fluid  ob- 
tained for  chemical  and  microscopical  examination. 

This  method  of  exploration  may  be  applied  to  all  pelvic  and  abdominal 
tumors,  with  the  best  results. 

In  the  use  of  the  aspirator  too  much  care  cannot  be  observed  as  to 
cleansing  the  needles  before  introducing  them.  The  fluid  of  ovarian  cysts 
is  often  withdrawn  by  them,  then  the  needle  used  is  carelessly  washed, 
put  aside,  and  again  used  at  the  infinite  risk  of  contamination  of  another 
patient.  Not  only  should  the  needles  be  scrupulously  cleansed  after,  but 
before  being  used  ;  and  immediately  before  introduction  they  should  be 
dipped  in  a  carbolized  solution. 

The  Microscope The  microscope  will  often  prove  useful  as  an  aid 

in  diagnosis  in  determining  the  malignant  nature  of  certain  morbid 
growths,  the  character  of  products  of  inflammation,  the  connection  of 
intra-uterine  growths  with  conception,  the  purulent  nature  of  uterine  leu- 
corrheea,  and  the  deleterious  effects  of  uterine  discharges  upon  the  zoo- 
sperm  in  the  production  of  sterility.  In  several  cases  of  obstinate  metror- 
rhagia dependent  upon  an  unascertained  cause,  I  have  been  able,  through 
cervical  dilatation  and  the  use  of  the  curette,  to  obtain  material  sufficient 
for  a  positive  diagnosis  of  sarcoma  or  cancer  of  the  body,  by  this  instru- 
ment. One  case  has  come  to  my  knowledge  in  which  many  of  the  symp- 
toms of  cancer  of  the  body  existed,  but  in  which  the  error  in  diagnosis 
thus  created  was  corrected  by  a  removal  of  a  portion  of  the  supposed 
morbid  growth  and  examination  by  the  microscope.  By  this  instrument 
the  substance  was  pronounced  to  be  not  cancer  but  sponge,  and  further 
investigation  proved  that  one-half  of  a  sponge-tent  had  remained  in  the 
body  of  the  uterus  for  several  months.  A  similar  case  has  been  reported 
to  me,  in  which  a  piece  of  cotton  was  long  retained,  giving  rise  to  very 
anomalous  symptoms.  A  portion  being  removed,  the  microscope  revealed 
its  true  nature. 


AUSCULTATION    AND    PERCUSSION.  Ill 

Of  late,  Foulis  and  Thornton  liave  pointed  out  the  important  fact  that 
examination  of  the  abdominal  effusion  accompanying  cancer  of  the  ovaries 
reveals  the  cancer-cell,  and  leads  to  a  correct  diagnosis ;  and  Drysdale 
has  proved  the  great  value  of  the  microscope  in  examination  of  ovarian 
fluids  and  the  determination  of  the  diagnosis  by  them. 

Auscultation  and  Percussion The  important  assistance  of  aus- 
cultation and  percussion  in  mapping  out  the  size  of  tumors,  determining 
pregnancy,  differentiating  this  from  ovarian  cysts,  etc.,  is  so  evident  as 
merely  to  require  a  passing  mention. 

RECAPITULATION  OF  MEANS  FOR  EXPLORING-  TIIE  VISCERA  AND  TISSUES 

OF  TIIE  PELVIS. 

1st.   Vagina  and  Cervix — 

Vaginal  touch  ; 

Sight,  through  the  speculum  ; 

Conjoined  manipulation. 
2c?.    Outer  Surface  of  the  Uterus — 

Vaginal  and  rectal   touch,  while   the  organ   is  brought  within 
reach  by  hypogastric  pressure  or  the  tenaculum; 

Conjoined  manipulation ;      „ 

Vesico-rectal  exploration ; 

Simon's  method. 
3d.     Cavity  of  Cervix  and  Body — 

Tents,  followed  by  introduction  of  finger. 

The  uterine  probe  and  sound. 

Removal  of  substance  by  curette  and  use  of  microscope. 
Aths   The  Ovaries,  Broad  Liyaments,  Pelvic  Peritoneum,  and  Pelvic 
Areolar  rTissue — 

Vaginal  touch  ; 

Rectal  touch  ; 

Simon's  method ; 

Conjoined  manipulation ; 

Abdominal  palpation  ; 

Auscultation  and  percussion  ; 

The  exploring  needle ; 

The  aspirator. 

It  is  so  difficult  for  a  teacher  to  give  instruction  to  a  class  upon  the  sub- 
ject of  diagnosis  of  the  diseases  of  women  that  I  am  induced  by  that  con- 
sideration to  give  a  representation  of  a  manikin  figure  which  has  given 
me  great  satisfaction  in  this  connection. 

This  figure  is  made  of  thick  board,  painted  to  resemble  the  human 
female,  the  legs  being  articulated,  and  the  whole  fixed  to  a  table  like  that 
represented  in  Figs.  G  and  7.     Upon  the  part  representing  the  trunk  all 


112  CONGENITAL    AND    INFANTILE    MALFORMATIONS 

the  abdominal,  thoracic,  and  pelvic  organs  are  painted  except  the  uterus. 
In  place  of  this  a  peg  or  pivot  is  fixed,  and  upon  this  uteri,  of  all  shapes 
and  sizes,  flexed,  with  tumors,  enlarged,  inverted,  etc.,  may  be  fixed  to 

Fig.  29. 


Manikin  figure  for  teaching  diagnosis. 

illustrate  cases  presenting  themselves  clinically.  After  examination  on 
the  back,  the  figure  is  placed  in  Sims's  position,  the  table  elevated  at  one 
side,  and  the  speculum  and  sound  are  employed.  The  sense  of  sight  is 
made  to  supplement  that  of  hearing,  and  instruction  is  made  clearer  by 
this  means. 


CHAPTER   VI. 

CONGENITAL  AND  INFANTILE  MALFORMATIONS  OF  THE  FEMALE 
SEXUAL  ORGANS. 

Many  cases  of  disease  are  due  to  congenital  malformation  of  the  ovaries, 
or  uterus,  or  to  deformities  arising  from  arrest  of  or  disproportionate  de- 
velopment during  girlhood.  Up  to  the  period  of  puberty  the  uterus, 
ovaries,  and  vagina  are  unimportant  organs  in  the  female  economy.  At 
that  time  they  rapidly  develop  and  immediately  assume  most  important 
relations.  During  their  period  of  insignificance,  even  if  the  most  striking 
malformation  exist,  it  produces  no  evil  result,  and,  unless  some  accidental 
circumstance  reveal  it,  is  not  recognized  or  even  suspected.  Puberty 
arrives,  the  girl  becomes  a  woman,  and  all  is  changed.  Upon  the  efficient 
performance  of  the  functions  of  ovulation  and  menstruation  are,  for  the 
next  thirty-five  or  forty  years,  to  depend  in  great  degree  the  health,  the 
usefulness,  and  the  happiness  of  the  woman. 


OF  THE  FEMALE  SEXUAL  ORGANS. 


113 


Preparatory  to  the  performance  of  these  functions  the  pelvic  viscera 
have  been  steadily  though  very  slowly  developing,  and  now  with  great 
suddenness  an  important  duty  is  thrown  upon  them.  If  during  uterine  life 
their  development  has  been  defective,  or  if  during  the  period  intervening 
between  birth  and  puberty  they  have  either  not  sufficiently  grown  or  have 
grown  in  such  a  manner  as  to  be  misshapen,  then  are  they  incompetent  to 
the  performance  of  the  duties  required  of  them,  and  certain  diseased  con- 
ditions are  the  result. 

I  shall  consider  only  the  most  important  of  these,  and  it  must  be  borne 
in  mind  by  the  student  that  their  importance  must  not  be  estimated  by 
the  possibility  of  their  relief.  The  recognition  of  the  fact  that  a  patholo- 
gical state  is  irremediable  and  that  treatment  for  it  is  unadvisable  is  always 
a  matter  of  as  great  moment  as  the  ascertaining  that  a  more  fortunate  state 
of  affairs  exists.  In  all  departments  of  medicine,  but  especially  in  gyne- 
cology, treatment  which  accomplishes  no  good  necessarily  tends  to  the 
production  of  evil. 

Development  of   Generative    Organs In   the    lumbar  regions  of  the 

foetus,  before  the  end  of  the  second  month,  the  anatomist  Wolff  discovered 
two  bodies,  each  consisting  of  a  large  number  of  tubes  closed  at  one  ex- 
tremity and  by  the  other  opening  into  a  common  excretory  canal.  These 
have  since  been  known  as  the  Wolffian  bodies,  and  from  them  essentially 
spring  the  male  internal  organs  of  generation,  but  not  so  the  female.  At 
the  inner  border  of  each  Wolffian  body  lies  a  germ  which,  remaining  un- 
changed until  the  second  month,  develops  into  the  ovary  of  one  side,  while 
the  Wolffian  body  gradually  becomes  atrophied. 

From  the  inner  sides  of  these  descend  two  ducts,  called  the  ducts  of 
Miiller,  which  passing  downwards  side  by  side  unite  at  a  point  just  below 
one  where  the  urethra  of  the  foetus 
begins  to  show  its  rudimentary  form- 
ation. At  about  the  end  of  the 
second  month,  these  ducts  begin  to 
approach  each  other  more  nearly  at 
a  point  in  the  pelvis,  and,  gradually 
coalescing  and  their  inner  walls  dis- 
appearing, the  vagina  and  cervix, 
and,  at  a  later  period,  the  corpus 
uteri  are  created.  The  upper  por- 
tions of  the  ducts  passing  off  to  each 
side  obliquely  constitute  in  the  future 
the  Fallopian  tubes.  Fig.  30  will 
show  the  coalescence  of  the  Miiller- 
ian  ducts  in  the  foetal  sheep. 

A  rudimentary  vagina,  Fallopian  tubes,  and  uterus  are  thus  formed, 
and  gradually  go  on  to  full  development  during  the  rest  of  foetal  life.     Any 


Fig.  30. 


Coalescence  of  Miillerian  ducts  in  a  ftetal 
sheep.      (I.  Miiller.) 


114 


CONGENITAL    AND    INFANTILE    MALFORMATIONS 


arrest  of  development  affecting  the  ducts  of  Miiller,  any  imperfection  of 
them,  or  any  failure  in  coalescence  of  the  two  ducts,  even  when  fully  de- 
veloped, inevitably  gives  rise  to  malformation  or  deformity.  Some  of  these 
produce  grave  consequences  at  puberty ;  others  are  so  wanting  in  result 
that  the  functions  of  the  woman  are  healthily  performed  in  spite  of  them. 
Their  very  existence  even  may  never  be  revealed,  or  be  discovered  only  by 
accident  towards  the  end  of  or  after  menstrual  life. 

The  varieties  of  congenital  malformation  of  these   parts  which  I  shall 
consider  are  the  following  : — 

Hypertrophy  of  the  uterus. 

Absence  or  rudimentary  state  of  uterus,  ovaries,  or  vagina. 

Unicorn  and  bicorn  uterus. 

Double  and  divided  uterus  and  vagina. 

Congenital  misplacement  of  the  uterus. 
Hypertrophy  may  affect  the  foetal  uterus  and  ovaries,  and  as  a  result  the 
child  be  born  with  this  organ  and  the  external  genitalia  as  fully  developed 
as   they  should   normally  be  at  puberty.     In   these   monsters  by  excess  of 

Fig.  31. 


A.  P.,  ap-fd  4  years  and  9  months.     Menstruated  regularly  from  the  age  of  21  months. 


development,  the  most  remarkable  sexual  precocity  sometimes  shows  itself. 
Instances  are  recorded  in  which  menstruation  began  at  birth  or  within  a 
month  after,  and  one  case  of  undoubted  authenticity  is  reported  in  which, 
menstruation  beginning  at  two  years,  parturition  at  full  term  occurred  when 
the  mother  was  only  eight.  Fig.  31  represents  a  girl  whose  case  was 
brought  to  my  notice  some  years  ago. 


OF  THE  FEMALE  SEXUAL  ORGANS.  115 

I  have  seen  another  case  in  which  menstruation  began  at  eight  months 
and  continued  regularly. 

Absence,  and  Rudimentary  Development,  of  Uterus  and  Ovaries At 

times  an  entire  failure,  not  only  of  coalescence  but  of  development,  occurs 
in  Midler's  ducts.  The  Fallopian  tubes,  uterus,  and  vagina  are  all  absent, 
and  very  often  in  such  cases  the  ovaries  likewise.  In  other  cases  the 
uterus  is  absent,  while  the  vagina,  Fallopian  tubes,  and  ovaries  are  devel- 
oped, coalescence  of  the  ducts  having  failed  while  development  above  and 
below  has  occurred. 

Entire  absence  of  the  uterus,  tubes,  and  ovaries,  as  proved  by  post- 
mortem examination,  not  by  physical  exploration  during  life,  is  of  so  rare 
occurrence  that  some  pathologists  have  doubted  its  existence.  When  it 
occurs  it  usually  does  so  in  infants  who  suffer  from  want  of  development 
of  the  lower  half  of  the  body.  It  must  be  borne  in  mind  that  sometimes 
rudimentary  uterine  horns  exist  which,  in  a  physical  examination,  can- 
not, even  by  the  most  practised  touch,  be  distinguished  from  portions 
of  the  oviducts  and  ovaries.  In  some  cases  of  undoubted  rudimentary 
uterus  only  a  slight  nodular  hard-  * 
ness  can  be  discovered  where 
the  uterus  should  be,  which  feels 
like  an  aggregation  of  areolar 
tissue  only.  There  can  be  little 
doubt  that  these  cases  are  clini- 
cally often  classed  with  those  of 
absence  of  the  uterus. 

The  rudimentary  uterus  is  of- 
ten accompanied  by  a  similar 
condition  of  the  ovaries,  vagina, 
and  even  the  mamnue  and  ex- 
ternal genitalia.  In  such  cases 
the  vagina  will  often  be  found  as 

.  .  Bow-shupecl  rudiment  of  uterus.     (Jfega.) 

a  cul-de-sac  measuring  only  one 

or  two  inches.  This,  however,  under  sexual  efforts  long  and  persever- 
ingly  continued,  often  undergoes  great  elongation  and  development. 
"When  this  fails  the  urethra  sometimes  undergoes  dilatation,  and,  being 
penetrated  by  the  virile  organ,  acts  as  a  vicarious  vagina. 

The  rudimentary  uterus  usually  appears  under  one  of  these  forms:  a 
thin  membranous  expansion  spreads  from  the  extremities  of  the  Fallopian 
tubes  and  round  ligaments  towards  the  vagina;  a  round,  hard,  two-horned 
solid  body  marks  the  site  of  the  uterus;  a  flattened,  crescentic  line  of  tissue 
occupies  the  site  of  the  uterus,  extending  across  the  pelvis  with  its  convex 
surface  looking  upwards ;  the  cervix  being  entirely  wanting,  the  sem- 
blance of  a  body  is  present  without  a  cavity;  the  body  with  cornua  exists, 
but  without  perforating   canal  ;  or,  lastly,  the  cornua  exist  with  cavities 


116  CONGENITAL    AND    INFANTILE    MALFORMATIONS 

within  them,  while  the  body  and  cervix  uteri  are  both  very  rudimentary 
in  their  development. 

Since  the  days  of  modern  gynecology,  this  anomaly  has  been  found  to 
be  of  not  very  rare  occurrence ;  previous  to  that  period  many  cases  went 
undetected  because  uninvestigated.  The  attention  of  the  physician  is 
usually  drawn  to  their  existence  by  the  fact  that  the  girl  arriving  at  six- 
teen or  seventeen  years  has  never  menstruated,  and  her  relatives  have 
become  apprehensive;  or  marriage  is  anticipated,  and  the  girl  or  her 
mother,  unwilling  to  assume  its  responsibilities  while  mystery  exists  with 
reference  to  so  important  a  subject,  desires  investigation ;  or  the  girl,  suf- 
fering from  uterine  enlargement,  the  result  of  retention  of  menstrual  blood, 
is  accused  of  illegitimate  pregnancy  and  is  brought  for  the  physician's 
decision  of  the  matter;  or,  worse  than  all,  marriage  has  been  contracted, 
the  husband  not  having  been  candidly  dealt  with,  sexual  intercourse  has 
been  found  to  be  impossible,  and  he  brings  his  wife  for  examination. 

In  such  cases  the  physician's  duty,  if  he  be  cognizant  of  the  facts  before 
marriage,  is  too  clear  to  require  mention.  So  grave  does  the  law  regard  a 
fraud  of  this  kind  that  it  is  considered  a'sufficient  ground  for  divorce.  The 
physician  may  likewise  be  consulted,  as  I  myself  have  twice  been,  as  to 
the  propriety  of  marriage,  the  man  knowing  perfectly  the  imperfections  of 
his  proposed  wife,  and  appreciating  that  not  only  are  menstruation  and 
conception  impossible  but  sexual  intercourse  likewise.  As  long  as  the 
laws  of  physiology  hold  true,  so  long  will  it  be  the  duty  of  the  medical 
adviser  to  oppose  under  such  circumstances  the  contraction  of  a  tie  which 
must,  unless  the  husband  be  more  or  less  than  man,  prove,  in  a  short  time, 
a  source  of  sorrow  and  disappointment. 

The  evils  which  result  from  this  distressing  anomaly  of  sexual  develop- 
ment are  not  merely  the  remote  and  contingent  ones  just  mentioned; 
there  are  others  which  are  almost  inherent  to  it.  These  are  absent  in 
the  most  decided  cases  of  want  of  development,  and  present  in  those  which 
are  less  complete.  Thus  if  uterus,  ovaries,  and  vagina  be  really  absent 
or  decidedly  rudimentary,  the  woman  may  pass  a  long  life  if  she  does  not 
contract  marriage,  not  only  without  suffering,  but  without  knowledge  of 
her  imperfection.  If,  however,  a  complete  atresia  exists  in  the  lower  por- 
tion of  the  uterus  only  or  upper  portion  of  the  vagina,  while  the  ovaries  are 
suliiciently  developed  for  ovulation  to  occur,  menstrual  blood  collects,  dis- 
tends the  uterine  cavity,  sometimes  regurgitates  through  the  tubes,  or 
ruptures  them,  or  furnishes  material  for  septic  absorption. 

Such  cases  sometimes  terminate  fatally  from  these  causes,  and  not 
rarely  from  the  results  of  surgical  procedures  adopted  for  their  relief. 
They  will  be  elsewhere  considered  in  reference  to  this  aspect  of  the 
subject. 

Where  the  uterus  is  almost  or  entirely  absent  and  the  ovaries  present, 
the  most  aggravated  derangements  of  the  nervous  system,  hysteria,  epilepsy, 


OF  THE  FEMALE  SEXUAL  ORGAN'S.  117 

and  mental  disorders  sometimes  show  themselves.  In  such  a  case  seen  in 
consultation  by  Drs.  Peaslee,  Emmet,  and  myself,  extirpation  of  the 
ovaries  was  decided  upon  and  performed  by  Dr.  Peaslee.  Unfortunately 
the  result  was  a  fatal  one.  In  a  similar  anomaly  mentioned  by  Duplay,1 
a  post-mortem  examination  gave  unequivocal  evidences  of  ovulation. 
Repeated  small  hematoceles  must,  of  course,  have  been  the  consequence, 
as  neither  oviducts  nor  uterus  existed. 

The  question  of  treatment  in  such  cases  turns  entirely  upon  the  pro- 
priety of  the  surgical  resource  of  opening  a  free  passage  through  the  atresic 
cervix  uteri  or  vagina,  for  the  escape  of  menstrual  blood  already  impris- 
oned, or  for  that  which  may  be  in  the  future  excited  to  flow  by  therapeutic 
means  adopted  for  that  purpose.  Before  adopting  and,  as  is  equally  import- 
ant, before  discarding  these,  a  thorough  exploration  should  always  be  made, 
and  the  manifold  dangers  of  the  operation,  together  with  its  decided 
chances  of  failure,  should  be  carefully  considered.  A  great  deal  of  unwar- 
rantable surgery  has  been  indulged  in  in  such  cases  from  neglect  of  these 
two  duties. 

Physical  Examination  of  such  Cases — The  patient  should  be  anaesthe- 
tized, and  placed  upon  the  back  upon  a  table,  and  the  legs  flexed  by  two 
assistants.  Then,  the  sphincter  ani  being  gently  stretched,  the  index  and 
middle  fingers  of  the  left  hand  should  be  carried  far  up  the  rectum,  and  con- 
joined manipulation  carefully  practised  for  detection  of  the  uterine  body. 
To  this  may  be  added  the  approximation  of  the  posterior  wall  of  the  blad- 
der to  the  fingers  in  the  rectum  by  a  sound  in  the  bladder,  or,  if  necessary, 
by  resort  to  introduction  of  the  index  finger  of  the  right  hand  through  the 
urethra  in  cases  difficult  of  decision.  There  are  no  other  means  of  physical 
exploration  at  our  command,  but  these,  intelligently  practised,  are  very 
reliable  if  preceded  by  anaesthesia,  as  they  should  always  be. 

But  he  who  in  these  cases  relies  for  his  decision  upon  physical  signs 
alone  will  surely  be  misled  ;  rational  ones  are  of  equal  importance  as  a 
guide  to  surgical  interference.  A  large  hard  fibrous  mass  may  be  found 
in  the  position  of  the  uterus,  and  yet  the  grave  operation  for  atresia  vagina? 
might  not  be  advisable.  If  menstrual  blood  is  discovered  imprisoned  ;  if 
a  distinct  period  of  excitement  or  malaise  marking  ovulation  can  be  traced ; 
or  if  the  otherwise  perfect  development,  good  health,  and  slight  obstruc- 
tive deformity  which  exist,  all  point  to  the  probability  that  the  hard  mass 
in  the  site  of  the  uterus  is  that  organ  with  fair  degree  of  development, 
the  patient  should  be  encouraged  to  submit  to  operation.  If,  on  the  other 
hand,  there  be  no  trace  of  accumulated  menstrual  blood  ;  no  evidences  of 
an  ovular  nisus  ;  and  none  by  physical  means  of  distinct  presence  of  a 
mass  in  the  uterine  site,  he  who  resorts  to  operation  is  exposing  his  patient 
to  an  unwarrantable  risk. 

1  Klob,  Anat.  Fern.  Sex.  Org.,  p.  43. 


118 


CONGENITAL    AND    INFANTILE    MALFORMATIONS 


Unicorn,  Bicorn,  Double,  and  Divided  Uterus — Sometimes  the  Miil- 
lerian   ducts  develop  into  the   two  halves  of  the  uterus,  but,  coalescing 

badly,  or  tbe  walls  dividing  tube 
from  tube  not  being  obliterated  by 
absorption,  deformities  of  less 
gravity  than  those  just  mentioned 
^  may  result.  One  horn  alone  may 
develop  while  the  other  fails  to 
do  so  ;  both  horns  may  develop  but 
unite  only  at  the  cervix  ;  or  both 
horns  may  develop,  and  although 
they  coalesce  perfectly  their  internal  walls  may  not  disappear,  and  thus  a 
septum  remain  which  divides  the  cavity  into  two. 


Bicorn  uterus.     (Sehroeder.) 


Fig.  34. 


Unicorn  uterus.     (Sehroeder.) 


The  accompanying  figures  will  give  a  very  good  idea  of  these  deformi- 
ties by  arrest  of  development. 


Fig.  35. 


Fir..  36. 


Double  uterus.     (From  specimen  in  possession 
■  if  author.) 


Divided  uterus.     (Kussmaul.) 


Some  of  these  deformities  create  great  difficulties  in  diagnosis  and  curi- 
ous problems  in  physiology :  such,  for  example  of  the  former,  as  cases  in 
which  menstrual  blood  becomes   imprisoned   in   one   dilated  uterus  while 


OF  THE  FEMALE  SEXUAL  ORGANS.  119 

the  other  remains  empty  ;  and  of  the  latter,  instances  in  which  a  child  is 
horn  at  full  term  from  one  uterine  cavity,  and  in  two  or  three  months 
another  from  the  other,  or  in  which  a  white  and  mulatto  child,  the  off- 
spring of  different  fathers,  are  produced  at  the  same  parturient  act. 

Ordinarily  these  malformations  produce  no  evil,  and  it  is  prohahle  that 
only  a  very  small  proportion  of  them  come  to  the  knowledge  of  the  patient 
or  physician.      They  require  no  treatment. 

Congenital  Misplacement  of  the  Uterus Sometimes  the  uterus  is  placed, 

hy  reason  of  its  peculiarity  of  development,  ohliquely  across  the  pelvis, 
inclining  to  one  or  other  side  ;  or,  one  half  developing  more  decidedly  and 
rapidly  than  the  other,  a  congenital  latero-flexion  exists;  or,  the  fundus 
heing  flattened,  what  is  called  the  anvil-shaped  uterus  results.  The  chief 
importance  of  the  recognition  of  these  states  is  connected  with  prognosis 
and  the  futility  of  treatment  for  their  removal. 

Absence  and  Rudimentary  State  of  the  Ovaries — The  ovaries,  as  well 
as  the  uterus,  may  he  either  not  developed  at  all  or  very  imperfectly  so. 
These  organs  arise  ahout  the  end 

of  the  second  month  of  foetal  life  •     '• 

from  a  germ  at  the  side  of  the  .^-oasS**5^:?^  rca>x  2 

Wolffian    hodies.      As    they    de-  /^y    O    It    £$%  1 

velop,  the  outer  covering  dips  in,      6  $P*§&  - 1     6-gb. 

as  shown  in  Fig.  37,  to  make  the         ^y^y  \ 

Graafian  follicles,  which  contain  \  j;  p 

the  ova,  the  discharge  of   which  fll le- 

af stated   periods   Constitutes    the  development  of  Graafian  vesicles.     (Kuss. 

r  Physiology.) 

great    function    of    these    glands 

and  the  characteristic  feature  of  the  female  sex.  Sometimes  these  organs 
contain  few  if  any  follicles,  and  are  incompetent  to  their  duty  in  the  econ- 
omy. The  results  of  this  arrest  of  perfect  development  are  amenorrhuea 
and  sterility,  which  usually  prove  entirely  rebellious  to  treatment. 

The  activity  with  which  this  reduplication,  and  formation  of  follicles  goes 
on,  may  be  judged  of  by  Sappey's1  statement  that  Kolliker  counted  in  a 
fetal  ovary  more  than  six  thousand. 

Absence  and  Rudimentary   State   of    Vagina Like    the   uterus   the 

vagina  is  created  by  union  of  the  Mullerian  ducts,  and  like  it  also  is  sub- 
ject to  a  variety  of  malformations,  due  to  an  arrest  of  development  or  fail- 
ure of  complete  union.  The  chief  of  the  anomalies  thus  created  are 
diminutive,  rudimentary,  unilateral,  and  atresic  vagina.  Some  of  these 
are  productive  of  no  evil  consequences  and  require  no  treatment;  others 
will  be  considered  under  the  heads  of  Atresia  Vaginas  and  Retention  of 
Menstrual  Blood. 

Anomalies  of  Uterine  Derelopme?U  during  Childhood. — The  uterus  is 

1  Courty,  Mai.  de  l'Uterus,  p.  66. 


120  CONGENITAL    AND    INFANTILE    MALFORMATIONS. 

an  organ  which  varies  greatly  at  different  periods  of  life  in  size  and  shape. 
In  the  fajtus,  the  girl  at  puherty,  the  nulliparous  woman,  the  multiparous, 
and  the  old  woman  who  has  lived  beyond  the  menopause,  it  is  a  different 
organ  in  these  respects.  In  the  first  the  neck  is  disproportionately  large, 
in  the  second  the  body  and  neck  gradually  become  equal  in  size,  in  the 
third  the  size  of  the  body  preponderates,  in  the  fourth  the  cavity  of  the 
body  enlarges  and  the  os  externum  changes  its  shape,  and  in  the  fifth  a 
general  physiological  atrophy  occurs,  which  diminishes  the  size  of  the 
whole  uterus,  though  affecting  the  body  somewhat  more  than  the  neck. 

It  is  the  changes,  and  the  anomalies  which  mark  them,  occurring 
between  birth  and  the  establishment  of  puberty,  which  are  now  to  receive 
attention.  During  this  time  the  uterus  very  slightly  develops  until  puberty 
is  reached,  when  the  rapid  development  of  that  period  shows  itself"  espe- 
cially in  this  organ.  During  childhood  the  uterine  body  is  bent  forwards, 
an  anteflexion  existing.  This  gradually  passes  off,  leaving  only  a  slight 
antecurvature,  to  last  through  life,  as  the  changes  of  puberty  cause  the 
uterine  walls  to  become  dense  and  resistant.  At  puberty,  as  Boivin  and 
Duges  pointed  out,  and  as  Cusco1  more  particularly  insisted  upon,  one 
wall  sometimes  develops  rapidly,  while  the  other  correspondingly  under- 
goes atrophy.  Anteflexion,  or  more  rarely  retroflexion,  is  the  result,  and 
the  first  menstrual  effort  is  attended  by  pain  and  obstruction.  Any  influ- 
ence which  presses  the  abdominal  viscera  down  upon  the  uterus  while  yet 
this  organ  is  soft  and  yielding  tends  to  develop  this  anomaly,  which  has 
received  the  name  of  congenital  flexion. 

Again,  the  foetal  uterus  with  its  disproportionately  long  neck  may  dis- 
appear, and  still  the  organ,  now  well  proportioned,  may  not  undergo  de- 
velopment at  puberty,  but  may  remain  small  and  unprepared  for  its  com- 
ing functions.  This  constitutes  the  incompletely  developed  uterus  of 
Kiwisch,  Rokitansky,  and  Scanzoni,  the  pubescent  uterus  of  Puesch,  and 
the  congenital  atrophy  of  other  writers. 

This  condition  is  marked  by  tardy  occurrence  of  menstruation,  and  by 
a  feeble,  irregular,  and  scanty  discharge ;  a  marked  tendency  to  complete 
amenorrhea  existing. 

Fortunately  a  good  deal  of  benefit,  under  these  circumstances,  often 
results  from  treatment  calculated  to  attract  nervous  influence  and  nutrition 
to  the  deficient  organ.  The  most  reliable  of  these  are  the  cautious  and 
svstematic  use  of  small  tents,  the  employment  of  an  intra-uterine  galvanic 
stem,  a  current  of  electricity  passed  through  uterus  and  ovaries,  and  the 
complete  establishment  of  the  general  health  by  exercise  and  tonic  treat- 
ment. 

In  some  of  these  cases  the  most  unfortunate  results  show  themselves  in 
connection  with  the  nervous  system.     In  two  cases  I  have  seen  epilepsy, 

•  Thfese,  a  Paris,  1853. 


DISEASES    OP    THE    VULVA.  121 

and  in  one  mental  imbecility,  which  seemed  to  be  clearly  traceable  to  the 
absence  of  sexual  development. 

Even 'when  no  general  symptoms  show  themselves,  the  undeveloped 
condition  which  characterizes  these  cases  to  a  certain  extent  incapacitates 
the  female  for  the  duties  of  wife  and  mother. 


CHAPTER  VII. 

DISEASES  OF  THE  VULVA. 

Normal  Anatomy The  vulva  is  the  elliptical  opening  which  exists 

at  the  distal  extremity  of  the  vagina,  and  comprises  the  mons  veneris, 
labia  majora  and  minora,  clitoris,  meatus  urinarius,  vestibule,  fossa  navi- 
culars, fourchette,  and  hymen. 

Labia  Majora — From  the  mons  veneris,  which  consists  of  adipose 
tissue  covered  by  skin  in  which  exist  numerous  hair-bulbs,  two  folds  of 
integument  pass  downwards  to  unite  at  the  fourchette.  These  are  called 
the  labia  majora.  Externally  they  are  covered  by  skin,  which  contains 
scattered  hair-bulbs,  but  on  their  inner  surfaces  their  covering  is  mucous 
membrane,  which  is  studded  with  sebaceous  follicles,  the  secretion  of 
which  is  unctuous  and  semi-solid.  These  glands  are  remarkably  large, 
reaching,  according  to  E.  Klein,1  a  diameter  of  0.5  millimetre.  They 
open  immediately  upon  the  free  surface. 

Within,  the  labia  are  filled  with  adipose  tissue,  a  portion  of  which  is 
inclosed  in  sacs,  of  which  one  arises  from  each  external  abdominal  ring 
and  extends  downwards  towards  the  fourchette.  To  these  Broca  lias 
given  the  name  of  dartoid  sacs. 

The  Clitoris — Beneath  the  superior  commissure  of  the  labia  juts  for- 
ward a  little  erectile  organ,  which  is  analogous  to  the  penis  of  the  male, 
and  receives  the  name  of  clitoris.  It  is  covered  by  mucous  membrane, 
consists  of  erectile  tissue,  and  arises  by  two  rami,  one  of  which  is  attached 
to  each  ramus  of  the  pubes.  Like  the  male  penis,  this  little  organ  is  pro- 
vided with  a  prepuce  and  framum. 

Labia  Minora These  consist  of  two  folds  which,  arising  at  the  clitoris, 

pass  downwards  and  disappear  about  half  way  between  the  two  commis- 
sures. Like  the  clitoris  they  are  formed  of  erectile  tissue  covered  over  by 
mucous  membrane,  and  an  attentive  examination  discovers  upon  their 
surfaces  a  large  number  of  glands,  which  secrete  a  sebaceous  material. 

The  Fossa  Navicularis  and  Vestibule  are  merely  spaces  intervening ; 

1  Strieker's  Manual  of  Histology. 


122  DISEASES    OP    THE    VULVA. 

the  first,  between  the  perineum  and  vagina;  the  second,  between  the 
meatus  and  clitoris.  They  are  both  covered  by  mucous  membrane,  and 
the  latter  is  studded  with  follicles. 

The  Hymen  is  a  thin  veil  consisting  of  a  double  fold  of  mucous  mem- 
brane, which  in  part  closes  the  ostium  vaginae.  When  ruptured  its  re- 
mains can  be  distinctly  discovered,  sometimes  not  at  all  diminished  in 
bulk,  upon  the  walls  of  the  vagina. 

Passing  over  the  clitoris,  to  which  it  is  attached,  and  running  down- 
wards on  each  side  of  the  vulva  so  as  in  part  to  cover  the  bulbi  vestibuli, 
will  be  found  a  muscle,  which  is,  I  think,  very  generally  regarded  as  the 
sphincter  vaginae.  Savage1  denies  that  it,  the  bulbo-cavernous  muscle, 
has  any  such  influence,  the  true  sphincter  vagina;  being  the  pubo-coccygeus 
muscle,  which  is  seen  by  dissection  within  the  pelvis,  arising  from  the 
inner  surface  of  the  pubic  bones.  Descending  on  the  sides  of  the  vagina 
some  of  its  fibres  pass  between  it  and  the  rectum  to  meet  others  from  the 
opposite  side  in  the  perineum.  Another  set  go  behind  the  rectum,  and 
uniting  with  similar  ones  from  the  opposite  side,  intermix  with  its  circular 
fibres  to  make  the  internal  sphincter.  The  remaining  fibres,  still  more 
outward,  are  inserted  in  the  sides  of  the  coccyx. 

Vulvitis. 

Definition Vulvitis  is  the  name  applied  to  inflammation  of  the  mu- 
cous membrane  lining  the  vulva.  Affecting  all  of  this  structure,  the 
surface  covered  by  epithelium  and  the  glands  imbedded  in  it,  the  inflam- 
matory action  sometimes  extends  through  the  submucous  tissue  into  the 
proper  structure  of  the  parts  underlying  it,  creating  tumefaction,  pain,  and 
sometimes  even  suppuration. 

Varieties Authorities  differ  with  regard  to  the  classification  of  its 

varieties. 

That  which  appears  most  appropriate  is  the  following: — 
Purulent  vulvitis ; 
Follicular  vulvitis. 

There  is  a  variety  of  the  affection  also  which  is  styled  gangrenous,  but 
it  is  so  entirely  confined  to  children  that  its  consideration  here  would  be 
out  of  place. 

Purulent   Vulvitis. 

This  variety  of  the  affection  may  be  either  of  non-specific  form,  or  a 
true  gonorrhoea  of  the  vulva.  The  former  is  in  many  respects  analogous 
to  balanitis  in  the  male,  while  the  latter  resembles  very  closely  specific 
inflammation  in  other  mucous  membranes  of  the  body. 

1  Female  Pelvic  Organs,  3d  ed. 


VULVITIS.  12o 

'Causes It  may  result  from 

Vaginitis,  specific  or  simple; 

Want  of  cleanliness ; 

Injury,  or  friction  from  exercise; 

Eruptive  disorders; 

Onanism; 

Chemical  irritants; 

Excessive  venery. 

Symptoms The  parts  are  red,  swollen,  hot,  and  at  first  dry.     Then  a 

free  flow  of  pus  takes  place  which  bathes  the  whole  surface  and  stains  the 
linen  of  a  yellow  hue.  In  addition  to  these  signs  of  active  inflammation, 
superficial  ulcers  will  be  found  scattered  over  the  parts  affected,  and  in 
rare  cases  patches  of  diphtheritic  membrane  will  be  seen  adhering  to 
them.  At  times  the  meatus  urinarius  becomes  affected,  and  painful  mic- 
turition, with  scalding  and  heat,  is  complained  of.  At  others  the  most 
intense  pruritus  affects  the  vulva,  and  the  patient,  in  endeavoring  to  ob- 
tain relief,  may  contract  the  habit  of  masturbation.  Should  the  inflamma- 
tion extend  to  the  vagina,  the  symptoms  of  vaginitis  will  also  show  them- 
selves, and  by  a  similar  extension  to  the  bladder  those  of  cystitis  may 
develop.  In  severe  cases  febrile  action,  with  thirst,  heat  of  skin,  and 
general  discomfort,  is  present,  but  this  is  not  usually  the  case. 

The  pus  which  is  discharged,  always  in  the  specific  form  of  the  disease, 
and  very  generally  in  the  non-specific,  gives  forth  a  disagreeable  odor, 
and  is  usually  so  irritating  in  its  nature  as  to  excoriate  the  inner  surfaces 
of  the  thighs  when  it  comes  in  contact  with  them.  Should  this  material, 
even  in  the  non-specific  form  of  the  affection,  be  carelessly  brought  in 
contact  with  the  conjunctivae,  a  severe  form  of  purulent  ophthalmia  is  ex- 
cited. The  late  Professor  Bedford  gave  me  the  account  of  a  case  in  which 
coition  under  such  circumstances  gave  rise  to  a  urethritis  in  the  male, 
which  was  made  the  basis  of  a  suit  for  divorce.  He  was  applied  to  as  a 
medical  expert,  and  found  upon  examination  that  non-specific  purulent 
vulvitis,  uncomplicated  by  vaginitis  or  urethritis,  existed. 

Course  and  Termination. — Even  without  treatment  it  is  probable  that 
the  affection  would  always  be  recovered  from  in  time ;  but  it  would  run  a 
lengthy  and  tedious  course,  and  perhaps  give  rise  to  complications  which 
would  be  productive  of  greater  evil  than  f lie  original  disorder.  When 
properly  treated,  it  generally  runs  a  rapid  course  and  is  readily  cured. 

Treatment — If  inflammatory  action  be  excessive,  the  patient  should  be 
kept  in  bed,  upon  low  diet,  and  the  bowels  freely  acted  upon  by  saline 
cathartics.  Emollient  applications  should  be  made  constantly  to  the  in- 
flamed part,  and  cleanliness  scrupulously  observed.  The  patient  should 
be  directed  to  bathe  the  vulva  freely  with  warm  water  three  or  four  times 
daily,  and  to  apply  a  warm  poultice  of  powdered  linseed,  slippery  elm,  or 


124  DISEASES    OF    THE    VULVA. 

grated  potato.     To  the  poultices  may  be  added  with  advantage  a  solution 
of  acetate  of  lead  and  tincture  or  powder  of  opium. 

As  soon  as  the  acute  action  has  subsided,  the  lead  and  opium  wash 
should  be  kept  in  contact  with  the  parts,  by  dossils  of  lint  soaked  in  it 
and  placed  between  the  labia.     It  is  thus  compounded: — 

R.  Tr.  opii,  §ij. 

Plumbi  acetat.  3J« 
Aqua?,  Oj. — M. 

At  a  still  later  period  the  diseased  surface  should  be  painted  over  sev- 
eral times  a  day  with  a  solution  of  persulphate  of  iron  and  glycerine,  one 
part  of  the  former  to  eight  of  the  latter.  Should  the  disorder  not  be 
entirely  eradicated  by  this  treatment,  the  vulva  may  be  painted  over  once 
in  every  forty-eight  hours  with  a  solution  of  nitrate  of  silver,  ten  grains 
to  the  ounce  of  water,  and  kept  constantly  powdered  with  lycopodium, 
bismuth,  or  starch,  until  recovery  is  complete.  Should  pruritus  attend 
the  latter  stages  of  the  disorder,  a  wash  composed  of  one  scruple  of  car- 
bolic acid  to  one  pint  of  water  will  be  found  useful. 

Follicular  Vulvitis. 

Definition  and  Synonyms — It  has  been  already  stated  that  in  the  mu- 
cous membrane  lining  the  vulva,  more  especially  in  that  covering  the 
labia  majora,  labia  minora,  and  vestibule,  numerous  follicles  exist.  Pre- 
senting themselves  as  solitary  glands,  they  are  classified  under  the  three 
following  heads — muciparous,  sebaceous,  and  piliferous.  In  ordinary 
purulent  vulvitis,  these,  as  component  parts  of  the  diseased  membrane, 
are  implicated  in  the  morbid  action.  Sometimes,  however,  they  alone  are 
affected  by  disease,  when  the  name  of  follicular  vulvitis  or  vulvar  follicu- 
litis has  been  applied  to  the  condition.  Any  or  all  of  the  varieties  of 
glands  just  mentioned  may  be  diseased,  and  authors  have  given  special 
names  to  the  varieties,  so  that  a  list  which  would  comprise  them  all  would 
be  a  long  one.  As  examples  may  be  mentioned  papillary,  pruriginous, 
erythematous,  sebaceous,  granular  vulvitis,  etc. 

"We  may  avoid  tediousness  of  detail,  and  at  the  same  time  run  no  risk 
of  being  led  into  error,  by  classing  all  forms  of  inflammation  affecting  the 
solitary  glands  of  the  vulva  under  the  head  of  follicular  vulvitis  ;  provided 
that  we  bear  in  mind  that  all  the  varieties  of  glands  maybe  simultaneously 
affected,  or  that  one  set  alone  may  be  diseased,  the  others  remaining 
healthy. 

Causes This  form  of  vulvitis  may  be  induced  by  the  following  in- 
fluences : — 

Pregnancy ; 

Neglect  of  cleanliness ; 

Vaginitis ; 

Exanthemata ; 

Eruptions  on  the  vulva. 


VULVITIS. 


125 


Symptoms — There  are  burning,  itching,  and  heat  in  the  vulva,  with  in- 
crease of  glandular  secretion.  At  times  the  secretion  is  excessively  offen- 
sive  and    irritating    in  character. 

The    urethra  frequently  becomes  Fio.  38. 

inflamed  at  its  vulvar  extremity, 
and  scalding  in  the  passage  of 
urine  results.  The  vulva  may 
become  so  sensitive  to  touch,  that 
efforts  at  sexual  intercourse  excite 
vaginismus,  which  thus  constitutes 
a  symptom  of  the  disease. 

Physical  Signs If  the  muci- 
parous follicles  be  chiefly  affected, 
the  mucous  membrane  of  the 
vulva  will  be  found  intensely  red 
in  spots  or  patches,  which  are 
slightly  elevated.  These  are  most 
commonly  found  on  the  edges  of 
the  lower  vaginal  ruga1:,  the  nym- 
phae,  and  the  caruncuhe.  They 
sometimes  resemble  the  swollen 
villi  upon  the  tongue,  and  bleed 
upon  slight  irritation. 

Should  the  disease  have  affected 
chiefly  the   sebaceous   and  pilife- 

rous  glands,  little,  red,  rounded  papilla?  will  be  found  on  the  surfaces  of 
the  labia  majora  and  minora,  and  the  base  of  the  prepuce  of  the  clitoris. 
After  a  while  a  drop  of  pus  will  appear  in  the  apex  of  each,  which  is  soon 
discharged,  and  the  distended  follicle  shrivels.  Beneath  the  labia  minora 
a  semi-fluid  mass  of  offensive  secretion  will  generally  be  found,  which 
will,  if  not  carefully  removed,  conceal  the  follicles  underlying  it. 

Course  and  Duration — If  this  disorder  occur  during  pregnancy,  it  may 
disappear  at  its  conclusion.  In  some  cases  it  becomes  so  severe,  and  pro- 
duces such  annoying  symptoms,  that  abortion  is  induced  by  it.  If  it  exist 
in  the  non-pregnant  state,  and  be  not  appropriately  treated,  it  may  con- 
tinue for  an  unlimited  time  and  establish  urethritis,  not  only  in  the  patient, 
but  in  her  husband.  This  fact  should  be  especially  recollected,  for  a  sus- 
picion of  want  of  chastity  may  be  excited  in  the  mind  of  the  husband,  and 
serious  domestic  difficulty  result. 

Treatment Follicular  vulvitis  should  be  treated  upon  the  same  prin- 
ciples as  the  purulent  form  ;  by  repeated  ablution,  warm  poultices,  sedative 
washes,  and  local  alteratives,  especially  the  persulphate  of  iron  and  nitrate 
of  silver.     Dr.  Oldham,  who  was  one  of  the  first  to  enlighten  the  profes- 


Follicular  vulvitis.     (Huguier.) 


126  DISEASES    OF    THE    VULVA. 

sion  in  regard  to  this  affection,  placed  great  confidence  in  the  following 
prescription  : — 

5.  Acidi  hydrocyanici  dil.  3ij. 
Plumbi  diacetatis,  Qj. 
Olei  cacao,  Jjij. — M. 
S.  Apply  after  washing  the  parts  with  cold  water. 

The  chronic  form  of  this  affection,  which  is  fortunately  rarely  met  with, 
constitutes  a  really  formidable  and  uncontrollable  disease.  In  the  Ameri- 
can Journal  of  Obstetrics  will  be  found  a  remarkable  instance  of  it  re- 
ported by  Dr.  B.  F.  Dawson,  which,  as  typical  of  that  form  of  the  disor- 
der, is  worthy  of  especial  notice.  The  patient,  aged  sixty  years,  had 
suffered  from  follicular  vulvitis  since  the  age  of  sixteen,  and  after  consult- 
ing numerous  practitioners  in  vain,  had,  on  account  of  the  intolerable  itch- 
ing attending  the  disease,  been  induced  to  resort  to  opium  for  comfort, 
until  in  time  she  had  become  a  confirmed  opium-eater.  At  the  time  when 
the  history  was  given,  the  following  was  the  condition  of  the  vulva  :  "  On 
parting  the  labia,  which  had  to  be  done  with  the  utmost  gentleness,  as  the 
patient  suffered  and  flinched  at  every  attempt,  the  mucous  membrane  of 
the  labia,  as  well  as  the  fourchette,  was  found  completely  covered  over  by 
a  thick  cheesy  substance,  of  a  dirty  cream  color,  which  emitted  a  pecu- 
liarly offensive  odor."  This  condition  had  proved  so  entirely  rebellious  to 
treatment,  that  removal  of  the  entire  mucous  covering  of  the  vulva  which 
was  the  site  of  the  diseased  glands  had  to  be  resorted  to. 

Cyst  and  Abscess  of  the  Vulvo -Vaginal  Glands. 

Anatomy Just  anterior  to  the  hymen,  or  the  caruncula;  myrtiformes, 

will  be  found  on  each  side  a  little  opening,  sufficiently  large  to  admit  a 
small  probe  or  bristle.  This  opening  leads  through  a  canal  three-fifths  of 
an  inch  long,  which  is  the  excretory  duct  of  a  conglomerate  gland  which 
has  received  the  name  of  vulvo-vaginal  gland.  These  glands  are  found, 
one  on  each  side  of  the  ostium  vaginae,  between  the  vagina  and  the  as- 
cending branch  of  the  ischium,  from  which  they  are  distant  three-tenths 
of  an  inch,  and  lie  in  contact  with  the  transverse  artery  of  the  perineum. 
The  fact  that  they  are  separated  from  the  vagina  by  an  aponeurotic  pro- 
longation, lie  between  the  superficial  and  middle  layers  of  the  ischio-pubic 
fascia,  and  have  the  unyielding  ischium  on  one  side,  accounts  for  the  com- 
plete confinement  of  pus  forming  in  them,  and  its  not  being  discharged  by 
the  rectum  or  vagina.  They  were  described  by  Duverney,  Bartholinus, 
Morgagni,  and  their  immediate  successors,  but  in  time,  very  singularly, 
they  were  forgotten.  In  1841,  M.  Iltiguier,  of  Paris,  redescribed  them 
fully,  and  threw  much  light  upon  their  diseased  conditions. 

Sometimes,  their  months  becoming  occluded  by  adhesive  inflammation, 
their  secretion    is  retained,  and  they  undergo  great  enlargement  and  dis- 


INFLAMMATION    OF    THE     V  U  L  VO-  V  A  (i  I  N  A  L    GLANDS.       127 

tention.     At  other  times  suppurative  inflammation  is  set  up  and  abscess  is 

the  result. 

Causes The  eauses  of  inflammation  of  these  glands  are  very  much  (lie 

same  as  those  of  vulvitis,  of  which,  indeed,  this  affection  is  often  a  con- 
comitant disorder. 

Symptoms — There  are  heat  ahout  the  vulva,  pruritus,  and  pain  upon 
touch.  The  mouth  of  the  duct  is  red,  and  the  finger  pressed  over  the  site 
of  the  gland  discovers  a  hard,  painful,  and  perhaps  fluctuating  tumor  ahout 
the  size  of  a  small  hen's  egg.  Very  often  the  first  intimation  of  the  exist- 
ence of  the  disease  is  given  by  pain  during  the  sexual  act,  or  upon  manipu- 
lation. 

Differentiation — An  abscess  of  this  gland  is  generally  readily  distin- 
guished from  a  cyst  by  the  presence  of  the  ordinary  signs  of  inflammation, 
or,  when  cystic  distention  exists  without  inflammation,  the  locality  of  the 
round  mass  rolling  slightly  under  the  finger  without  tenderness  will  make 
the  diagnosis  clear.  From  phlegmonous  inflammation  of  the  labium  majus 
it  will  be  known  by  its  distinct,  globular,  and  limited  outline,  the  former 
affection  being  diffuse.  Furuncles  are  entirely  too  superficial  to  create 
confusion  in  diagnosis. 

Course  and  Duration This  disease  is  one  of  no  great  moment,  and  its 

natural  tendency  is  to  recovery.  Its  usual  duration  is  from  two  to  three 
weeks,  and  the  inflammatory  process  may  terminate  either  by  resolution 
or  by  suppuration.  Should  the  latter  occur,  the  pus  may  be  discharged 
through  the  ducts  of  the  gland,  or  in  the  furrow  between  the  labia  minora 
and  majora.  In  some  cases,  however,  the  gland  becomes  filled  with  a 
honey-like  matter,  and  exists  as  a  cyst  for  months,  and  even  for  years. 

Treatment — When  inflammation  affects  the  cyst  wall,  an  emollient 
poultice  or  cooling  and  anodyne  lotion  should  be  kept  applied  to  the  vulva, 
and  rest  should  be  prescribed  until  suppuration  has  occurred.  Then,  if 
pain  be  very  severe,  the  accumulated  pus  may  be  evacuated,  by  means  of 
a  lancet,  near  the  mouth  of  the  gland  or  at  any  other  point  where  fluctua- 
tion is  most  distinct.  If  pain  be  not  severe,  the  evacuation  of  the  pus 
may  be  left  to  nature. 

When  retention  of  the  contents  of  the  gland  has  created  a  cyst  unat- 
tended by  suppuration,  or  when  frequent  return  of  suppurative  action 
renders  a  radical  procedure  necessary,  it  has  been  advised  to  extirpate  the 
gland.  This  is  a  bloody  operation,  as  the  transversus  perinei  artery  is  apt 
to  be  severed.  In  all  my  experience  I  have  never  found  extirpation 
necessary,  and  have  practised  in  its  stead  the  procedure  which  I  shall  now 
describe. 

Catching  up  the  mucous  membrane  over  the  sac,  I  cut  out  with  scissors 
an  ellipse.  This  exposes  perfectly  the  wall  of  the  sac,  which  is  punctured 
by  the  tenaculum,  so  as  to  allow  the  escape  of  a  small  amount,  say  one 
third,  of  its  contents.     The  sac  wall  is  now  lifted  by  the  tenaculum,  and  an 


128  DISEASES    OF    THE    VULVA. 

elliptical  piece  is  cut  out  of  that  also.  This  prevents  closure  and  secures 
drainage.  The  cavity  is  now  filled  with  carbolized  cotton,  which  in  thirty- 
six  or  forty-eight  hours  is  removed. 

Eruptive  Diseases  of  the  Vulva. 

The  skin  and  mucous  membrane  making  up  the  vulva  may,  like  the 
same  structures  in  other  parts  of  the  body,  be  affected  by  eruptive  dis- 
orders of  various  kinds.  It  is  not  my  intention  to  enter  with  any  minute- 
ness into  the  consideration  of  tjiese  diseases,  for  which  I  refer  the  reader 
to  any  of  the  modern  works  upon  dermatology,  but  merely  to  note  the  fact 
that  they  may  occur  upon  this  part,  and  mention  the  leading  character- 
istics of  the  most  frequent  of  them. 

Any  eruptive  disorder  which  may  elsewhere  affect  the  skin  or  mucous 
membrane  of  the  body  may  show  itself  on  the  vulva.  The  following  list 
includes  those  which  are  most  commonly  met  with  and  most  frequently 
call  for  diagnosis  and  treatment: — 

Prurigo  and  lichen ; 
Eczema  ; 
Acne ; 

Elephantiasis  ; 
Erythema  and  erysipelas ; 
Syphilides. 

As  is  the  case  elsewhere  with  prurigo,  that  of  the  vulva  presents  large, 
scattered  papules,  very  irritating  and  generally  having  their  apices  bereft 
of  cuticle.  Lichen  shows  more  numerous  papules,  which  rest  upon  a 
thickened  and  somewhat  indurated  cutaneous  base.  Pruritus  vulva;  is  the 
most  prominent  symptom  of  these  maladies.  So  intense  is  the  irritation 
of  the  vulva  established  by  them  that  vulvitis  is  the  consequence,  the  dis- 
ease then  being  styled  pruriginous  vulvitis. 

In  eczema  the  surface  is  red,  heated,  and  covered  by  little  vesicles, 
which  breaking,  give  forth  a  serous  fluid.  The  eruption  confines  itself 
chiefly  to  the  cutaneous  surface,  the  mucous  lining  being  less  affected.  It 
may  pass  off  rapidly  as  an  acute  disorder,  but  sometimes  there  are  succes- 
sive crops  of  vesicles  which  exhaust  the  strength  of  the  patient,  in  conse- 
quence of  the  nervous  excitement  and  irritability  which  the  disease  induces. 
In  many  cases  of  diabetes  and  vesico-vaginal  fistula,  this  affection  consti- 
tutes an  exceedingly  annoying  and  even  painful  complication. 

Acne  consists  in  engorgement  of  the  sebaceous  follicles  studding  the 
labial  faces;  not  in  active;  inflammation,  which  would  bring  the  case  under 
the  head  of  follicular  vulvitis,  but  in  engorgement  by  their  own  retained 
secretion. 

Elephantiasis  of  the  labia  differs  in  nothing  from  that  of  other  parts. 
The  affection  is  very  rare.  Kiwisch  records  one  case  in  which  both  labia 
increased  in  size,  so  as  to  equal  the  head  of  a  man,  and  to  fall  nearly  to 


PHLEGMONOUS    INFLAMMATION    OF    LAI5IA    MAJORA.       129 

the  knees.  The  parts  affected  by  it  are  the  labia  majora  and  minora,  the 
clitoris,  and  the  perineum. 

Erythema  and  erysipelas  are  simply  accompanied  by  graver  symptoms 
when  they  affect  the  genital  organs  than  when  they  develop  on  the  skin 
elsewhere. 

Syphilis  in  secondary  and  tertiary  form  may  affect  the  labia,  creating 
hypertrophy,  ulceration,  and  all  the  evils  which  it  excites  in  other  parts. 

These  disorders  create  the  ordinary  symptoms  of  vulvitis,  and  hence 
they  are  commonly  confounded  with  it.  Pruritus  vulva?  is  one  of  their 
most  constant  signs,  and  the  itching  which  it  produces  often  first  attracts 
attention  to  their  presence. 

Treatment Little  need  be  said  here  of  treatment,  for  it  should  be 

guided  by  the  rules  which  govern  the  management  of  the  same  cutaneous 
disorders  in  other  parts  of  the  body.  The  general  health  should  be  care- 
fully attended  to ;  change  of  air  advised ;  and  tonics  and  alteratives,  such 
as  iron  and  arsenic,  prescribed  in  combination,  the  first,  with  Colombo,  or 
the  second,  with  the  tinctures  of  cinchona,  or  gentian.  Local  treatment 
should  consist  in  the  maintenance  of  strict  cleanliness  by  bathing  the  dis- 
eased parts  freely  in  tepid  water,  and  the  pruritus,  which  invariably  exists 
and  leads  to  scratching,  should  be  relieved  by  lotions  containing  acetate 
of  lead,  opium,  borax,  or  a  small  amount  of  creasote  or  carbolic  acid. 

Phlegmonous  Inflammation  of  the  Labia  Majora. 

The  areolar  and  adipose  tissues,  which  in  great  degree  make  up  the 
bulk  of  the  labia  majora,  are  very  frequently  the  seat  of  inflammation  and 
abscess.  The  disease  is  excited  by  irritating  vaginal  secretions,  vulvitis, 
direct  injury,  and  the  peculiar  blood  state  which  results  in  the  develop- 
ment of  furuncles  and  carbuncles. 

Symptoms In  the  first  stage  there  is  active  congestion,  which  in  the 

second  produces  hardness  and  tension  from  effusion  of  liquor  sanguinis 
into  the  areolar  tissue.     The  third  stage  consists  in  the  breaking  down  of 
this  mass  by  the  process  of  suppuration  and  formation  of  an  abscess.     The . 
pus  which  is  thus  created  is  usually  very  offensive  from  propinquity  to  the 
rectum  and  vulva. 

The  diagnosis  is  generally  very  easy.  Attention  is  directed  to  the  part 
by  heat,  pain,  throbbing,  difficulty  of  locomotion,  and  exquisite  sensitive- 
ness upon  pressure.  Upon  physical  exploration  one  labium  is  found  very 
much  swollen  and  quite  hard  and  tender.  Although  it  is  usually  easy  to 
distinguish  this  disease,  care  must  always  be  taken  to  differentiate  it  from 
labial  hernia,  displacement  of  an  ovary,  pudendal  hematocele,  oedema 
labiorum,  and  vulvitis.  As  this  point  will  engage  our  attention  elsewhere, 
it  requires  no  further  mention  here. 

Treatment The   treatment  should  consist,  in  the  first  stage,  in  the 

application  of  cold  and  sedative  lotions,  low  diet,  saline  cathartics,  and 
9 


130 


DISEASES    OF    THE    VULVA. 


perfect  rest.  One  of  the  best  local  applications  will  be  found  to  be  the 
lead  and  opium  wash.  As  the  second  stage  advances  the  process  of  sup- 
puration, which  is  now  inevitable,  should  be  encouraged  by  poultices,  and 
as  soon  as  pus  is  distinctly  discoverable  it  should  be  evacuated  by  punc- 
ture. Early  opening  is  advisable,  because  the  tissues  obstinately  resist 
natural  evacuation,  and  the  accumulation  may  pass  upwards  towards  the 
abdominal  ring  through  the  dartoid  sac. 


Rupture  of  the  Bulbs  of  the  Vestibule. 

Anatomy. — If  an  incision  be  made  by  a  scalpel  through  the  skin  and 
its  subjacent  adipose  tissue,  around  the  vulva,  and  all  the  tissues  making 
up  that  part  be  dissected  off,  a  reticulated  plexus  of  large  veins  will  be 
found  beneath  the  labia  called  the  pars  intermedia  and  bulbi  vestibuli. 
These  extensive  channels  for  blood  have  been  represented  by  Kobelt,  as 
shown  in  Fig.  39. 

Fig.  39. 


Plexus  of  veins  of  the  vestibule.     (Kobelt.) 

Any  influence  which  causes  a  rupture  of  these  vessels  must  produce  one 
of  two  effects:  if  there  be  a  corresponding  rupture  of  the  skin,  a  free 
hemorrhage  will  occur,  known  as  pudendal  hemorrhage ;  if  not,  the  blood 
pouring  out  into  the  areolar  tissue,  surrounding  the  wounded  plexus,  will 
soon  form  a  coagulum,  constituting  a  bloody  tumor,  which  has  received 
the  name  of  thrombus  or  pudendal  hematocele. 

Pudendal  Hemorrhage. 

Especial  attention  was  called  to  this  condition  by  Sir  James  Simpson,1 
who,  in  1850,  recorded  from  his  own  experience,  and  that  of  others,  a 

'  Obstet.  Works,  vol.  i.  p.  277,  Am.  ed. 


PUDENDAL    HEMATOCELE.  131 

number  of  instances  in  which  from  a  very  slight  rupture  of  one  labium 
fatal  hemorrhage  took  place.  He  declared  that  criminal  cases  had  repeat- 
edly occurred  in  Scotland,  in  which  women,  both  pregnant  and  non- 
pregnant, had  suddenly  died  from  pudendal  hemorrhage,  arising  from 
rupture  of  the  bulbs  of  the  vestibule.  Suspicion  of  injury,  at  the  hands  of 
the  husbands  or  neighbors,  had  been  entertained  in  most  or  all  of  the 
instances  referred  to. 

The  accident  is  a  rare  one.  But  two  instances  have  come  under  my 
notice,  one  occurring  in  consequence  of  puncture  of  the  labium  by  a  stick, 
the  woman  falling  in  crossing  a  fence ;  the  other  the  result  of  a  similar 
puncture  by  a  piece  of  china,  from  the  breaking  of  a  pot  de  chambre. 
Both  these  cases  readily  yielded  to  the  recumbent  posture,  and  the 
application  of  cold  and  styptic  compresses.  A  very  interesting  case,  the 
details  of  which  I  cannot  now  find,  was  published  some  time  ago  in  one  of 
the  journals  of  the  day.  A  lady,  standing  upon  a  chair  to  mount  a  horse, 
slipped  and  fell,  so  as  to  cause  the  sharp  extremity  of  one  of  the  upright 
pieces  to  puncture  one  labium.  Bleeding  was  profuse,  and  so  obstinate  as 
to  require  several  attempts  at  checking  it  before  it  was  finally  controlled. 
This  was  in  the  end  accomplished  by  a  tampon  in  the  vagina  and  firm 
compression  by  a  T  bandage. 

Causes — The  great  predisposing  causes  are  pregnancy,  varicose  condi- 
tion of  the  veins,  and  a  large  pelvic  tumor. 

The  exciting  causes  are — 

Great  muscular  efforts  ;* 
Blows  rupturing  the  labium  ; 
Incisions  or  punctures. 

Symptoms — The  hemorrhage  that  announces  the  accident  will  lead  to 
a  physical  exploration,  which  will  at  once  reveal  the  nature  of  the  lesion. 

Treatment — The  nature  of  the  accident  being  once  recognized,  the 
control  of  the  flow  will  not  usually  be  difficult.  If  it  be  not  effected  by 
cold  and  astringents,  such  as  ice,  the  persulphate  of  iron,  or  tannin,  the 
vagina  should  be  filled  with  a  firm  tampon  of  cotton,  a  folded  towel  applied 
as  a  compress  over  the  vulva,  and  a  T  bandage  made  to  press  this  forcibly 
against  the  body.  Should  this  plan  fail,  the  wound  should  be  enlarged  by 
incision  and  filled  with  pledgets  of  cotton  saturated  with  solution  of  per- 
sulphate of  iron ;  then  the  tampon  should  be  applied  in  the  vagina  and  a 
compress  carefully  adjusted  by  means  of  a  T  bandage.  It  is  difficult  to 
conceive  of  any  case  occurring  in  the  non-pregnant  woman  which  could 
resist  this  method  if  effectually  employed. 

Pudendal  Hematocele. 

Definition    and   Synonyms The    term    thrombus,   derived  from   the 

Greek  epojuSow,  "  I  coagulate,"  and  which  is  used  synonymously  with  hema- 

1  Prof.  Simpson  records  a  case  due  to  straining  at  stool. 


132  DISEASES    OF    THE    VULVA. 

toma  and  sanguineous  tumor,  is  that  which  is  generally  applied  to  this 
condition.  I  have  preferred  the  appellation  of  pudendal  hematocele, 
given  to  the  disorder  by  Dr.  A.  H.  McClintock,  from  its  pointing  out  the 
similarity  between  it  and  pelvic  hematocele,  which  resembles  it  in  patho- 
logy, and  because  the  term  thrombus  is  now  commonly  applied  to  the 
coagulation  of  blood  in  a  bloodvessel. 

A  pudendal  hematocele  is  a  tumor  formed  by  a  mass  of  clotted  blood 
effused  into  the  tissue  of  oue  labium,  or  the  areolar  tissue  immediately 
surrounding  the  wall  of  the  vagina. 

History. — As  early  as  1554,  the  disease  was  mentioned  by  Rueff,  of 
Zurich,  and  in  1647,  Veslingius  is  said  by  Dr.  Merrimen  to  have  noticed 
it.  It  attracted  the  attention  of  Kronauer,  of  Basle,  in  1734,  and  sub- 
sequently that  of  Levret,  Boer,  Audibert,  and  others.1  In  time  it  passed 
somewhat  out  of  notice,  until  the  researches  of  Deneux,2  in  1830,  drew 
attention  to  it  in  more  recent  times.  It  is  generally  alluded  to  by  authors 
only  as  one  of  the  results  of  pregnancy  and  parturition,  though  it  is  incon- 
testably  proved  that  it  may  occur  in  the  non-pregnant  and  even  in  the 
virgin  state.  Velpeau  records  an  instance  in  a  girl  of  fourteen  years,  who 
had  not  yet  arrived  at  puberty,  and  declares  as  the  result  of  his  experience, 
that  "  thrombus  vulvae  occurs  almost  as  frequently  in  non-pregnant  women 
as  in  those  who  are  in  labor."  He  declares  that  he  has,  in  the  course  of 
one  year,  observed  six  cases  in  the  non-pregnant  woman  ;  and  in  his  whole 
experience  he  has  met  with  twenty  instances  of  the  affection. 

At  the  same  time  that  I  defer  to  the  statement  of  so  reliable  an  authority 
as  Velpeau,  I  must  express  surprise  at  it.  The  accident  in  the  puerperal 
woman  is  not  very  rare,  but  my  experience  would  lead  me  to  regard  it  as 
extremely  so  in  the  non-puerperal,  since  in  a  practice  of  twenty-seven 
years  I  have  met  with  but  four  cases.  These  occurred  as  direct  results  of 
injuries  done  to  one  labium  by  a  severe  blow,  and  resembled  very  closely 
the  same  accident  which  occurs  so  often  around  the  eye.  Another  fact 
which  adds  to  my  surprise  is  this:  in  connection  with  this  subject  I  have 
carefully  examined  the  current  medical  literature  of  the  day,  and,  although 
it  teems  with  reports  of  this  affection  as  a  complication  or  sequel  of  labor, 
I  find  few  reports  of  instances  in  the  non-pregnant  woman.  Nevertheless, 
as  I  am  in  this  work  strictly  avoiding  the  study  of  the  diseased  states 
constituting  the  complications  and  sequela;  of  labor,  I  shall  specially  con- 
sider that  form  of  the  affection  which  occurs  in  the  non-puerperal  state. 

Pathology The    pathology  of  this    condition    is   similar   to    that  of 

pudendal  hemorrhage,  which  has  just  received  notice,  for  both  are  results 
of  rupture  of  the  bulbs  of  the  vestibule.  In  that  which  we  are  now  con- 
sidering, the  effused  blood,  instead  of  pouring  away,  collects  in  the  tissue 

1  Velpeau,  Diet,  de  M6d.,  vol.  xxx. 

8  Sur  les  Tumeurs  sanguines  de  la  Vulve  et  du  Vagin. 


PUDENDAL    HEMATOCELE.  133 

of  one  labium,  under  the  vagina,  or  even  in  the  areolar  tissue  of  the  pelvis, 
and  forms  a  coagulum.  It  bears  to  pudendal  hemorrhage  the  same  relation 
which  a  simple  fracture  bears  to  one  of  compound  character. 

Rupture  of  a  branch  of  the  ischiatic  or  pudic  artery  may,  during  labor, 
likewise  produce  a  bloody  tumor,1  but  this  should  not  be  treated  of  under 
the  technical  head  of  pudendal  hematocele,  for  it  would  really  constitute  a 
case  of  sub-peritoneal  hematocele. 

Mode  of  Development. — When  a  large  vessel  has  been  injured,  a  tumor, 
perhaps  the  size  of  an  orange,  is  suddenly  discovered  at  the  vulva.  At 
other  times  the  tumor  is  quite  small,  not  larger  than  a  walnut.  The  ex- 
tent of  the  laceration  likewise  governs  the  rapidity  with  which  the  tumor 
forms  after  the  injury  has  been  inflicted.  In  some  instances  a  slight  flow 
slowly  continues  until  compression  from  the  clot  checks  it.  When  the 
accident  occurs  in  the  non-pregnant  state,  the  amount  of  blood  effused  is 
generally  less  extensive  than  in  pregnancy,  and  is  usually  confined  to  the 
vulva. 

Causes. — The  causes  are  similar  to  those  of  pudendal  hemorrhage, 
namely : — 

Muscular  efforts ; 

Blows  injuring  the  labia; 

Punctures  by  small  instruments. 

Symptoms. — The  symptoms  are  usually  a  sense  of  discomfort,  with  pain 
and  throbbing,  and  if  the  effusion  reaches  the  urethra,  there  is  obstruction 
to  urination.  The  patient  or  attendant  will  often  first  recognize  the  fact 
that  something  abnormal  has  occurred  by  the  sense  of  touch,  practised 
without  a  suspicion  as  to  the  nature  of  the  real  difficulty. 

Differentiation.'1 — Care  must  be  observed  not  to  confound  this  affection 
with — 

Abscess  of  the  labia; 
Pudendal  hernia; 

Inflammation  of  vulvo-vaginal  glands  ; 
CEdema  labiorum. 
The  mere  announcement  of  the  possibility  of  error  in  diagnosis  is  all 
that  is  necessary,  for  the  physical  characteristics,  mode  of  development, 
and  rational  signs  of  these  affections  are  so  different  from  those  of  pudendal 
hematocele,  that  examination  will  always  settle  the  point  with  certainty. 
Prognosis — If  the  sanguineous  collection  be  small,  it  will,  especially  in 

1  Meigs's  Treatise  on  Obstetrics,  5th  ed.,  p.  94. 

2  I  have  ventured  to  use  this  term  in  place  of  "differential  diagnosis,"  giving 
it  the  signification  which  it  has  in  Natural  History,  instead  of  that  which  belongs 
to  it  in  Mathematics.  This  use  is  sanctioned  by  Worcester ;  and  Agassiz  speaks 
of  the  "differentiation  of  species."  Its  cognate  verb  is  equally  necessary  and 
convenient. 


134  DISEASES    OF    THE    VULVA. 

the  non-pregnant  state,  generally  disappear  spontaneously.  If,  however, 
it  be  large,  and  if  the  patient  have  recently  b§en  delivered,  there  are 
always  two  dangers  to  be  apprehended.  The  lesser  of  these  is  hemorrhage ; 
the  greater,  purulent  infection  through  the  walls  of  the  cyst,  or  the  forma- 
tion of  an  extensive  abscess,  which  may  produce  the  same  result.  These 
may  follow  in  the  non-puerperal  form  of  the  affection,  but  the  danger  of 
both  is  much  less  great  than  in  the  puerperal,  where  the  vessels  of  the 
part  are  largely  distended,  in  consequence  of  excessive  growth,  and  where 
the  blood  state  is  one  of  hydraemia  and  hyperinosis. 

Natvral  Course. — Should  the  tumor  be  left  to  itself,  it  maybe  absorbed 
in  a  short  time  and  leave  no  trace ;  in  five  or  six  days  it  may  burst  and 
discharge ;  the  clot  may  become  encysted,  and  remain  indefinitely  in  the 
tissues  ;  or  the  irritation  of  the  clot  may  create  suppurative  inflammation, 
and  abscess  of  the  labium  be  the  consequence. 

Treatment — Should  the  tumor  be  small,  and  not  excite  much  pain,  a 
cooling  lotion  of  lead  and  opium  should  be  applied,  the  patient  kept  quiet, 
and  the  evacuations  of  the  bladder  and  rectum  regulated,  in  the  hope  that 
absorption  will  take  place.  As  soon  as  evidences  of  phlegmonous  inflam- 
mation around  the  tumor  appear,  suppuration  and  discharge  should  be 
encouraged  by  poultices.  When  the  tumor  is  large,  and  experiment  has 
demonstrated  that  it  will  not  undergo  absorption,  it  is  advisable  to  evacu- 
ate the  blood-clot  by  incision.  This  should  be  done  by  means  of  a  bis- 
toury, upon  the  mucous  face  of  the  labium  majus,  the  patient  being  placed 
under  the  influence  of  an  anaesthetic.  After  an  incision  has  been  made, 
one  finger  should  be  inserted  and  the  clot  turned  out  of  its  nidus.  If  he- 
morrhages ensue,  the  sac  should  be  thoroughly  washed  out  with  a  solution 
of  the  persulphate  of  iron,  and  pressure  exerted.  Should  this  not  check 
it,  pledgets  of  lint  soaked  in  this  astringent  should  be  passed  into  the  sac, 
and,  if  necessary,  counter-pressure  exerted  per  vaginam  by  a  tampon  of 
cotton.  In  case  no  hemorrhage  should  follow  evacuation  of  the  cavity, 
no  vaginal  tampon  should  be  employed,  nor  should  the  empty  sac  be  filled 
with  cotton.  A  better  plan  under  these  circumstances  would  be  to  wash 
out  the  cavity  thoroughly  with  a  weak  solution  of  carbolic  acid  in  water, 
for  the  more  certain  avoidance  of  septicaemia  and  of  phlegmonous  inflam- 
mation. 

Pudendal  Hernia. 

Anatomy — By  some  anatomists  it  is  stated  that  the  round  ligaments  of 
the  uterus  end  in  the  mons  veneris;  but  this  view  is  incorrect.  A  more 
careful  dissection  traces  them  through  the  internal  abdominal  rings,  along 
the  inguinal  canals,  to  the  labia  majora,  where  they  are  lost  in  the  dartoid 
sacs,  described  by  Broca  as  passing  through  these  folds.  The  labia  ma- 
jora are  unquestionably  the  analogues  of  the  scrotum  of  the  male,  and  the 
round  ligaments   correspond  to  the  spermatic  cords.     Into  the  inguinal 


PUDENDAL    HERNIA.  135 

canals  these  ligaments  are  attended  by  a  prolongation  of  peritoneum  which 
has  received  the  name. of  the  canal  of  Nuck.  This  ordinarily  becomes 
obliterated  at  full  term  of  foetal  life,  but  not  always.  When  it  remains 
pervious,  the  formation  of  inguinal  hernia  is  favored. 

Definition Down  one  of  the  inguinal  canals,  by  the  side  of  the  round 

ligament,  a  loop  of  intestine,  and  sometimes  a  portion  of  the  mesentery,  an 
ovary,  the  bladder,  or  the  entire  uterus,  may  pass,  as  inguinal  hernia 
occurs  in  the  male. 

The  fact  that  this  disease  is  by  no  means  frequent,  makes  its  recog- 
nition the  more  important,  for  were  the  practitioner  not  aware  of  the 
possibility  of  its  occurrence,  the  intestine  might  be  wounded,  under  the 
supposition  that  the  labial  enlargement  was  due  to  abscess,  or  distention 
of  the  vulvo-vaginal  glands. 

Causes The  displacement  may  be  produced  by  violent  muscular  efforts, 

or  blows,  or  falls,  as  in  the  male. 

Symptoms Strangulation  of  the  intestine  with  its  characteristic  signs 

may  occur,  according  to  Sir  Astley  Cooper  and  Scarpa,1  although  it  is 
very  rare.  The  hernia  may  usually  be  overcome  by  taxis.  In  one  case 
with  which  I  met,  reduction  was  extremely  difficult,  and  could  only  be 
accomplished  by  prolonged  effort.  When  the  intestine  becomes  pro- 
lapsed, no  strangulation  existing,  a  sense  of  discomfort,  upon  bending  the 
body  or  even  upon  walking,  directs  the  patient's  attention  to  the  affected 
part,  and  leads  her  to  apply  to  the  physician.  By  him  the  nature  of  the 
case  will  at  once  be  suspected,  from  the  peculiar  gaseous  or  airy  sensation 
yielded  to  the  touch.  Certainty  of  diagnosis  will  be  arrived  at  by  absence 
of  all  signs  of  inflammation  or  oedema,  the  detection  of  impulse  upon 
coughing,  and  resonance  upon  percussion,  and  the  possibility  of  diminish- 
ing the  volume  of  the  tumor  by  taxis  and  position.  There  are  no  very 
great  difficulties  attending  the  differentiation  of  the  disease.  The  danger 
is  that  the  possibility  of  hernia  at  this  point  may  be  forgotten,  and  deduc- 
tions drawn  without  considering  it.  Although  the  probability  of  error  be 
not  great,  the  appalling  nature  of  the  accident  in  which  it  would  result, 
warrants  the  relation  of  the  following  case,  which  is  illustrative  of  its  pos- 
sibility. A  patient  called  upon  me  with  the  following  history:  she  had 
had  an  abscess  just  below  the  external  abdominal  ring,  which,  after  poul- 
ticing, had  been  evacuated  by  her  physician,  about  a  month  before  the 
time  of  her  visit  to  me.  After  this,  she  had  felt  well  until  a  week  before, 
when,  after  a  muscular  effort,  the  pain  had  returned  with  all  the  original 
signs  of  abscess,  and  these  had  continued,  although  she  had  painted  the 
part  steadily  with  tincture  of  iodine,  as  she  had  been  directed  to  do  in  case 
of  such  an  occurrence.  Being  in  great  haste  at  the  moment,  I  examined 
the  enlargement  while  the  patient  was  standing,  and  under  a  recent  cica- 

1  Scanzoni,  op.  cit.,  p.  560. 


136  DISEASES    OF    THE    VULVA. 

trix,  which  was  painted  with  iodine,  I  discovered  what  I  supposed  tQ  be  a 
reaccumulation  of  pus.  As  the  patient  came  to  me  in  the  absence  of  her 
physician,  merely  for  the  evacuation  of  this,  I  placed  her  in  the  recumbent 
posture,  and,  lancet  in  hand,  proceeded  to  operate.  But,  to  my  surprise, 
I  discovered  that  change  of  posture  diminished  the  size  of  the  enlargement. 
This  excited  my  suspicions,  and  I  found  that  a  recent  hernia  had  occurred 
under  the  old  cicatrix. 

Treatment. — The  patient  having  been  placed  upon  the  back  with  the 
hips  elevated  by  a  large  cushion,  or,  as  is  better,  by  elevation  of  the  foot 
of  the  bed  or  table  upon  which  she  lies,  the  tumor  should  be  grasped,  com- 
pressed, and  pushed  up  the  canal,  down  which  it  has  descended,  until  it 
returns  to  the  abdomen.  Then  a  truss,  so  arranged  as  to  press  upon  the 
inguinal  canal,  should  be  adjusted,  and  worn  with  a  perineal  strap,  to  keep 
the  compress  of  the  instrument  sufficiently  low  down  to  effectually  close 
the  point  of  exit.  Should  strangulation  have  occurred,  and  return  of  the 
prolapsed  part  by  taxis  prove  impossible,  the  case  will  require  the  surgical 
operation  for  that  condition,  for  a  description  of  which  the  reader  is  referred 
to  works  on  general  surgery. 

Hydrocele. 

Definition  and  Frequency This  affection,  which  consists  in  a  collec- 
tion of  fluid  in  the  inguinal  canal,  around  the  round  ligament,  is  one  of 
such  rarity  in  the  female  that  its  very  existence  is  commonly  ignored, 
and  mention  of  it  is  rarely  made  by  systematic  writers.1 

Anatomy It  has  been  already  stated  that    the  labia  majora  of  the 

female  are  analogous  to  the  scrotum  of  the  male,  and  that  the  round  liga- 
ments, which  are  analogous  to  the  spermatic  cords,  do  not  end  in  the  mons 
veneris,  as  was  formerly  supposed,  but  passing  downwards  enter  the  labia 
majora  and  distribute  their  filaments  within  the  dartoid  sacs,  which  ex- 
tend like  glove-fingers  downwards  towards  the  fourchette.  The  interest- 
ing and  valuable  article  of  M.  Broca  upon  this  subject  will  be  found  quoted 
at  length  in  Cruveilhier's  Anatomy.  The  peritoneal  covering  of  these 
ligaments  usually  extend  to  the  inguinal  canals,  but  occasionally  in  young 
subjects  it  is  prolonged  through  a  portion  of  the  canal  constituting  the 
canal  of  Nuck.'2  In  adults  this  is  ordinarily  obliterated,  and  hence  the 
rarity  of  hydrocele  and  hernia  in  the  female.  Sometimes  it  remains  per- 
manently open,  when  not  only  may  the  intestines  descend,  but  even  the 
ovary  may  pass  down,  making  an  attempt  to  enter  the  dartoid  sacs  and 
imitate  the  entrance  of  the  testes  into  the  scrotum. 

Pathology The  affection  which  we  are  now  considering  is  the  result  of 

excessive  secretion  on  the  part  of  this  serous  membrane,  which,  by  the 

1  Scanzoni's  work  upon  Diseases  of  Women  contains  an  account  of  it. 

2  Cyclopedia  of  Anat.  and  Phys.,  Supplement,  p.  706. 


HYDROCELE.  137 

fluid  collected  within  it,  is  distended  laterally  and  downwards.  Should  the 
abdominal  opening  of  such  a  sac  remain  pervious,  the  fluid  thus  collecting 
could  readily  be  forced  upwards  as  in  the  same  affection  in  the  male,  but 
if  that  opening  has  become  impervious,  the  fluid  becomes  sacculated  and 
such  return  is  impossible.  So  rare  is  this  affection  that  I  offer  no  apology 
for  the  introduction  of  the  following  instance  of  it,1  reported  by  Dr.  E.  P. 
Bennett,  of  Danbury,  Connecticut. 

"In  an  extensive  practice  of  over  forty  years,  but  one  single  case  has 
come  under  my  observation.  This  case  occurred  recently  in  a  young 
married  female  residing  in  Putnam  County,  and  was  mistaken  by  a  surgeon 
of  some  eminence  for  a  case  of  inguinal  hernia,  who  endeavored  to  reduce 
it,  but  failing  to  do  so,  pronounced  it  adherent,  and  irreducible,  and  ad- 
vised to  let  it  alone.  That  such  a  mistake  should  have  been  made  is  not  at 
all  surprising,  as  it  was  a  hydrocele  of  the  round  ligament  coming  down 
through  the  inguinal  canal,  and  occupying  exactly  the  place  of  inguinal 
hernia,  and  closely  resembling  one.  She  subsequently  came  under  my  care, 
and  upon  inquiry  I  learned  that  about  five  years  since  a  small  tumor  had 
made  its  appearance,  which  had  slowly  and  steadily  increased  in  size  until 
it  had  attained  its  present  size,  which  was  about  as  large  as  a  turkey's  egg. 
It  had  not  been  painful,  was  not  attended  with  abdominal  disturbance,  had 
never  receded  when  recumbent,  and  gave  to  the  touch  a  feeling  of  fluid 
contents  instead  of  the  doughy  feel  of  hernia,  and  I  therefore  thought  that, 
whatever  it  might  be,  it  was  not  hernia  ;  and,  upon  closer  inspection,  I 
diagnosed  hydrocele  of  the  round  ligament,  although  it  was  not  diaphanous. 
So  sure  Avas  I  of  a  correct  diagnosis  that  I  at  once  proposed  an  operation, 
to  which  she  readily  consented  ;  and,  with  the  aid  of  a  professional  brother, 
who  coincided  with  me  in  my  diagnosis,  I  proceeded  to  cautiously  lay  open 
the  sac,  when  we  found,  to  our  great  satisfaction,  that  wTe  had  not  blundered 
in  our  opinion.  The  serous  contents  of  the  sac  having  been  evacuated,  I 
injected  it  with  a  saturated  tincture  of  iodine,  and  she  speedily  recovered 
without  the  supervention  of  a  single  unpleasant  symptom.  This  case  is 
only  important  from  its  rarity,  and  the  fact  that  most  physicians  are  not 
aware  that  hydrocele  can,  or  ever  does,  occur  in  the  female  ;  and  my  object 
in  writing  this  article  is  not  to  record  any  remarkable  achievement  in  sur- 
gery, but  to  call  the  attention  of  physicians  to  this  subject,  and  thereby 
prevent  mistakes  which  might  be  attended  with  disastrous  results." 

A  pamphlet  has  been  published  upon  the  subject  by  Dr.  Hart,  of  this 
city.  In  it  he  details  an  operation  for  hernia  performed  in  a  case  of 
hydrocele  from  a  mistake  in  diagnosis.  The  fluid  of  the  hydrocele  being 
evacuated,  the  wound  was  closed  by  silver  suture,  and  the  patient  recovered. 
He  declares  that  the  disease  is  mentioned  by  Aetius,  Pare,  Scarpa,  Meckel, 
and  Poland. 

Differentiation The  greatest  circumspection  should  be  observed  before 

a  diagnosis  of  this   rare  malady  is  arrived  at.     The  sense  of  fluctuation, 

1  N.  Y.  Med.  Record,  Nov.  15,  1870. 


138  DISEASES    OF    THE    VULVA. 

with  entire  absence  of  symptoms  of  inflammation,  the  absence  of  reso- 
nance on  percussion,  and  the  ordinary  signs  of  hernia,  the  existence  of 
translucency,  and  the  gradual  development  of  the  tumor  without  pain  or 
constitutional  excitement,  would  all  be  reasons  for  suspecting  it.  But, 
before  ultimate  measures  are  adopted  for  its  cure,  a  very  fine  exploring 
needle,  such,  for  example,  as  that  of  the  ordinary  hypodermic  syringe, 
should  be  passed  in,  in  order  that  the  contents  of  the  sac  may  be  carefully 
examined. 

Should  the  character  of  this  fluid  not  assure  us  that  hernia  exists,  the 
smallest  needle  of  the  aspirator  should  be  introduced,  and  all  the  fluid 
drawn  off.  Even  where  hernia  exists,  such  a  procedure  has  been  found 
to  favor  return  of  the  sac,  and  to  do  no  harm  by  rendering  it  subsequently 
pervious. 

Treatment. — The  diagnosis  being  made,  the  treatment  should  consist  in 
evacuation  by  means  of  the  aspirator,  and,  if  cure  do  not  follow  this,  in  the 
injection  of  tincture  of  iodine  in  addition,  which  may  be  done  by  revers- 
ing the  action  of  the  same  instrument. 


CHAPTER  VIII. 

PRURITUS  VULVAE. 

Definition This  affection  consists  in  irritability  of  the  nerves  supply- 
ing the  vulva,  which  induces  the  most  intense  itching  and  desire  to  scratch 
and  rub  the  parts.  Although  not  itself  a  disease,  it  is  always  so  important, 
and  often  so  obscure  a  symptom,  that  it  requires  special  notice  and  in- 
vestigation. 

Pathology It  has  just  been  stated  that  it  consists  in  disorder  of  the 

nerves  supplying  the  vulva.  It  matters  not  whether  this  be  a  true  neu- 
rosis or  one  secondary  to  some  other  pathological  state,  the  great  element 
of  pruritus  vulvae  is  nervous  irritability  or  hyperesthesia.  That  it  is  often 
excited  by  irritating  discharges  and  eruptive  disorders  there  can  be  no 
question.  Whether  it  ever  depends  upon  idiopathic  nervous  hyperoesthe- 
sia,  as  some  suppose,  is  doubtful.  I  have  never  met  with  an  instance  in 
which  it  appeared  to  do  so. 

Mode  of  Development  and  Course — In  the  beginning,  the  irritability 
and  tendency  to  scratch  are  sometimes  very  slight,  so  as  to  annoy  the 
patient  very  little  and  give  her  but  trifling  uneasiness.  Sometimes  they 
exist  only  after  exertion  in  warm  weather,  upon  exposure  to  artificial  heat, 
or  just  before  and  after  menstruation.     The  disorder  is  aggravated  by  the 


PRURITUS    VULVAE.  139 

counter-irritation  which  it  demands  for  its  relief.  The  rubbing  and 
scratching  that  are  practised  cause  an  afflux  of  blood,  render  the  skin  ten- 
der and  its  nerves  sensitive,  and  in  time  greatly  augment  the  evil  by  pro- 
ducing a  papular  eruption.  The  disease  and  the  remedy  which  instinct 
suggests,  react  upon  each  other,  the  first  requiring  the  second,  and  the 
second  aggravating  the  first,  until  a  most  rebellious  and  deplorable  condi- 
tion is  developed.  It  would  be  difficult  to  exaggerate  the  misery  in  some 
of  these  cases.  The  patient  is  bereft  of  sleep  by  night,  and  tormented 
constantly  by  day,  so  that  society  becomes  distasteful  to  her,  and  she  gives 
way  to  despondency  and  depression.  The  itching  is  generally  intermit- 
tent, in  some  cases  occurring  at  night,  in  others  only  at  certain  periods  of 
the  day.  In  two  cases  that  I  have  met,  the  patients  were  free  from  all 
irritation  except  at  night,  when  the  disturbance  and  nervous  anxiety  be- 
came so  intense  as  to  prevent  sleep,  except  when  large  doses  of  opium 
were  given.  Loss  of  sleep,  the  use  of  opium,  and  the  nervous  disturbance 
incident  to  the  disease,  often  prostrate  and  exhaust  the  patient  to  an 
astonishing  extent. 

This  disorder  is  to  some  degree  paroxysmal,  any  influence  which  pro- 
duces congestion  of  the  genital  organs  aggravating  it  very  much.  Lying 
in  a  warm  bed,  sexual  intercourse,  eating  and  drinking,  more  especially 
highly  seasoned  food  and  stimulating  beverages,  and  the  act  of  ovulation, 
all  produce  this  result.  Its  duration  has  no  limit;  months,  and  even  years, 
sometimes  passing  before  relief  is  obtained. 

Although  the  term  "  pruritus  vulvae"  is  that  ordinarily  applied  to  it,  it 
must  not  be  supposed  that  the  irritation  is  always  coufined  to  the  vulva. 
It  often  extends  up  the  vagina,  to  the  anus,  and  down  the  thighs.  In 
pregnant  women  I  have  repeatedly  known  it  to  spread  over  the  abdomen. 
It  may  be  asked  why  such  a  state  should  be  styled  "  pruritus  vulvae  ?" 
These  extensions  are  merely  complications  of  the  original  malady  which 
really  deserves  that  name,  and  are  due  to  contamination,  by  scratching, 
with  an  ichorous  element  which  constitutes,  as  I  believe,  the  prominent 
exciting  cause  of  the  trouble. 

Causes. — Every  practitioner  dreads  to  meet  with  an  aggravated  case  of 
pruritus  vulva?,  for  he  knows  how  obstinate  the  malady  commonly  proves. 
The  only  reasonable  hope  of  controlling  it  must  rest  in  viewing  it  strictly 
as  a  symptom,  and  striving  to  discover  and  remove  its  cause.  No  fixed 
prescriptions,  however  much  lauded  for  their  efficacy,  should  be  relied 
upon.  The  primary  disorder  should  be  sought  for  and  cured,  in  the  hope 
of  removing  that  one  of  its  results  which  is  most  pressing  in  its  demands 
for  relief.  Should  the  case  have  progressed  for  some  time,  it  will  often  be 
found  impossible  to  decide  as  to  its  cause,  for  the  scratching  induced  by  it 
will  frequently  establish  a  cutaneous  disorder,  the  connection  of  which 
with  the  pruritus,  whether  as  cause  or  effect,  will  be  doubtful. 


140  DISEASES    OP    THE    VULVA. 

The  predisposing  causes  of  pruritus  are  the  following  : — 

Uterine,  vaginal,  or  urethral  disease; 

Pregnancy ; 

Depreciated  general  health  ; 

Hahits  of  indolence,  luxury,  or  vice ; 

Uterine  or  abdominal  tumors ; 

Want  of  cleanliness; 

Constitutional  syphilis ; 

Severe  exercise  in  one  of  sedentary  habits. 
It  will  be  observed  that  most  of  these  influences  are  those  which  pre- 
dispose to  the  development  of  abnormal  secretion  by  the  mucous  membrane 
lining  the  genital  tract.  Such  excessive  and  deranged  secretion  I  believe 
to  be  in  the  great  majority  of  cases  the  immediate,  exciting  cause  of  the 
nervous  irritation.  That  there  are  other  causes,  it  will  be  seen  that  I 
admit,  but  to  treat  this  condition  successfully,  I  am  convinced  that  special 
reference  must  be  had  to  this  element.  He  who  simply  keeps  in  view  the 
local  trouble,  in  the  majority  of  cases  will  be  striving  merely  against  the 
branches  of  an  evil,  the  root  of  which  consists  in  the  ichorous  material, 
which  bathes  and  excoriates  the  terminal  extremities  of  the  nerves  of  the 
vulva  and  vagina. 

In  all  the  instances  of  pruritus  vulvae  that  I  have  been  able  to  examine 
early  enough  to  determine  as  to  the  etiology,  I  have  found  one  of  the  fol- 
lowing conditions  to  exist  as  the  apparent  cause  of  the  hyperaesthetic  con- 
dition of  the  nerves  : — 

1st.    Contact  of  an  irritating  discharge — 

Leucorrhoea ; 

Hydrorrhea ; 

Discharge  of  cancer; 

Dribbling  of  urine; 

Diabetes. 
2d.    Local  inflammation — 

Vulvitis ; 

Urethritis ; 

Vaginitis; 

Aphthous  ulcers. 
3d.    Local  irritation — 

Eruptions  on  the  vulva; 

Animal  parasites; 

Onanism; 

Vegetations  on  the  vulva; 

Vascular  urethral  caruncles; 

Growth  of  short,  bristly  hair  on  mucous  face  of  labia. 
Of  all  these,  leucorrhcea  is  the  most  frequent  cause.     This  symptom  of 
uterine  disorder  fortunately  produces   pruritus  only  as  an  exception  to  a 


PRURITUS    VULViE.  141 

rule.  Under  certain  circumstances  it  appears  to  possess  peculiarly  irri- 
tating and  excoriating  qualities,  which,  even  when  the  flow  is  insignificant 
in  amount,  will  excite  the  most  intolerable  itching.  This  feature  is  most 
commonly  observed  in  the  discharge  attending  pregnancy;  and  in  that  of 
senile  endometritis,  which  covers  the  vagina  with  bright  red  spots,  and 
gives  it  a  glazed  look  like  serous  membrane.  In  an  exceedingly  obstinate 
case,  occurring  in  a  woman  of  seventy  years,  the  leucorrhceal  discharge 
was  so  small  in  amount  that  the  patient  was  not  aware  of  its  existence, 
nor  did  I  appreciate  its  connection  with  the  disorder  until  I  discovered 
accidentally  that  the  only  relief  which  could  be  obtained  followed  the  ap- 
plication of  a  wad  of  cotton  against  the  cervix  uteri.  In  every  case  of 
pruritus  the  vagina  should  be  carefully  investigated  for  evidence  of  leu- 
corrho3a,  unless  some  other  sufficient  cause  is  apparent.  In  the  same 
manner  the  other  discharges  mentioned  may  cause  nervous  irritability  in 
the  vulva. 

It  is  not,  however,  usually  vaginal  leucorrhoea  which  produces  the  re- 
sult ;  it  is  much  more  commonly  due  to  the  discharge  arising  from  cervical 
or  corporeal  endometritis,  and  the  obstinacy  of  these  affections  accounts 
to  some  extent  for  that  of  the  secondary  one. 

I  have  so  often  found  diabetes  accompanied  by  this  symptom  that  I 
always  examine  the  urine  in  obscure  cases.  It  is  by  many  attributed  to 
the  constitutional  agency  of  the  disease.  The  marked  relief  afforded  by 
the  systematic  use  of  the  catheter  has  led  me  to  think  otherwise.  My 
impression  is  that  the  pruritus  is  probably  not  connected  with  the  consti- 
tutional effects  of  the  disease  upon  the  nerves,  but  with  the  direct  and 
local  influence  exerted  by  the  disordered  secretion. 

Local  inflammation,  by  the  discharge  which  it  excites  and  the  itching 
which  attends  it,  is  very  evidently  calculated  to  give  rise  to  pruritus;  and 
yet  cases  thus  established  are  not  the  most  rebellious  with  which  we  meet. 

Any  form  of  eruption  upon  or  around  the  vulva  may,  and  usually  does, 
excite  itching.  Eczema,  prurigo,  lichen,  and  many  others,  may  do  so 
here  as  they  do  elsewhere,  and  the  natural  warmth  of  the  part,  formed  as 
it  is  of  folds  of  tissue  and  covered  by  hair  which  is  thickly  interspersed 
with  sebaceous  and  piliferous  glands,  makes  them  the  more  likely  to  prove 
active  in  causing  it. 

Animal  parasites  of  two  varieties  may  give  rise  to  it,  the  pediculus 
pubis  and  the  acarus  scabiei.  The  first  excites  through  irritation  a  liche- 
noid eruption,  Avhile  the  second  produces  scabies,  or  itch. 

One  of  these  causes  will  generally  be  found  to  have  given  rise  to  pruritus 
vulvae,  but  it  is  only  in  originating  the  difficulty  that  it  will  prove  active. 
Very  soon  secondary  influences,  as  eruptions,  excoriations,  ulcerations, 
and  increased  discharges,  the  results  of  scratching,  superadd  themselves 
as  auxiliary  agents,  and  keep  up  the  disorder. 

Treatment It  has  been  stated  that  the  first  effort  of  the  practitioner 


142  DISEASES    OF    THE    VULVA. 

should  always  be  to  discover  the  disease  of  which  the  pruritus  is  a  symp- 
tom, and  then  to  endeavor  to  remove  it  by  appropriate  means.  Should 
leucorrhoea  be  the  cause,  the  uterine  or  vaginal  affection  which  gives  rise 
to  it  should  be  treated.  Should  an  eruptive  disorder  be  found  to  be  the 
source  of  the  difficulty,  the  measures  which  would  be  advisable  for  this 
affection  elsewhere  developed,  laxatives,  baths,  change  of  air,  tonics,  and 
arsenic,  would  be  equally  beneficial  here. 

But  this  alone  will  not  be  sufficient.  "While  eradication  of  the  mischief 
is  thus  attempted,  palliative  means  must  be  vigorously  adopted  for  the 
sake  of  present  relief.  Should  the  case  be  regarded,  upon  careful  investi- 
gation, as  due  to  contact  of  an  irritating  fluid  with  the  nerves  of  the  vulva, 
perfect  cleanliness  should  be  secured  by  three,  four,  or,  if  necessary,  a 
larger  number  of  sitz  baths  daily,  and  the  vagina  should,  at  the  time  of 
taking  each  bath,  be  syringed  out  with  pure  or  medicated  water.  The 
irritated  surface  should  be  protected  by  unctuous  substances,  or  inert  pow- 
ders, such  as  bismuth,  lycopodium,  or  starch,  from  the  injurious  contact, 
and  in  case  the  discharge  comes  from  the  uterus,  a  wad  of  cotton  should 
be  placed  daily  against  the  cervix  uteri  to  prevent  its  escape  to  the  vulva, 
or,  as  is  better,  after  a  thorough  use  of  the  vaginal  douche  the  vagina 
should  be  thoroughly  tamponed  daily  with  cotton  saturated  with  glycerine 
to  which  has  been  added  borax  or  acetate  of  lead,  two  drachms  to  the 
ounce.  Of  this  plan,  which  I  should  mention  does  not  confine  the  patient 
to  bed,  T  can  speak  in  high  terms.  While  it  protects  the  vulva  from 
ichorous  discharges,  it  does  not  prevent  ablution  and  applications  to  the 
point  of  maximum  irritation.  A  very  useful  vaginal  injection,  and  wash 
for  the  vulva,  under  these  circumstances,  is  the  following: — 

I£.  Plumbi  acetatis,  5U- 
Acidi  carbolici,  £)ij. 
Tr.  opii,  sj. 
Aqua?,  Oiv. — M. 

This  may  relieve  itching  for  a  time,  until  removal  of  the  cause  of  the 
symptom  is  accomplished. 

In  case  the  pruritus  is  the  result  of  a  local  inflammation,  this  should  be 
treated  as  elsewhere  recommended,  by  poultices  of  linseed,  potato,  or  slip- 
pery elm,  to  which  have  been  added  a  proper  amount  of  lead  and  opium ; 
or  fomentations  of  lead  and  opium  wash,  or  poppy-heads  may  be  used  in 
their  stead.  If  vaginitis  or  vulvitis  be  present,  great  relief  will  often  be 
obtained  by  painting  the  lining  membrane  of  the  diseased  part  over  with 
a  strong  solution  of  nitrate  of  silver,  or  by  touching  the  whole  surface  very 
lightly  with  the  solid  stick,  and  then  using  the  tampon  of  cotton  and 
glycerine. 

Should  an  eruptive  disorder  be  the  exciting  cause,  it  should,  as  already 
stated,  be  treated  upon  general  principles.  Meantime  temporary  relief 
may  be  obtained  by  painting  the  surface  of  the  vulva  over  with  a  solution 


PRURITUS    VULViE.  113 

of  nitrate  of  silver,  or  the  use  of  the  ungt.  creasoti,  ungt.  chloroformi,  or 
ungt.  atropise  of  the  U.  S.  Dispensatory.  Dr.  Simpson  advises  an  infu- 
sion of  tobacco,  and  Dr.  J.  C.  Osborn,1  of  Alabama,  in  an  interesting 
article  upon  the  medicinal  use  of  this  drug,  declares  that  he  always  re- 
sorts to  a  strong  decoction  of  it  as  a  wash  for  the  vagina  and  vulva  in 
this  affection,  and  for  the  anus  in  "  prurigo  podicis."  According  to  the 
hitter  gentleman  the  local  sedative  effects  of  tobacco  are  very  useful  in  the 
control  of  prurigo.     My  own  experience  agrees  with  his. 

Although  the  fact  will  probably  not  prove  one  of  practical  value,  it  is 
certainly  one  of  interest  that  cases  have  recently  been  reported  in  which 
smoking  tobacco  has  appeared  to  relieve  pruritus.  As  an  illustration  I 
quote  the  following:  "Mrs.  TV".,2  a  woman  of  nervous  temperament,  be- 
came pregnant  a  few  months  after  her  marriage.  In  addition  to  the  usual 
derangement  of  the  alimentary  canal,  she  soon  experienced  a  severe  itching 
all  over  her  body.  The  skin  was  of  a  perfectly  normal  appearance;  the 
pruritus,  however,  caused  her  great  excitement  and  soon  produced  nervous 
spasms.  For  several  weeks  every  possible  external  and  internal  remedy 
was  used  in  vain.  A  decoction  of  walnut  leaves  gave  her  some  relief  when 
in  the  seventh  month  of  pregnancy.  Then  a  violent  pyrosis  and  neuralgia 
of  the  dental  nerves  supervened.  In  order  to  alleviate  the  latter,  she  was 
advised  by  her  husband  to  try  the  effect  of  smoking,  when  the  pain  as  well 
as  the  itching  and  pyrosis  disappeared  immediately.  Mrs.  W.  smoked  one 
cigar  every  evening  until  she  was  prematurely  delivered  by  a  fright,  after 
8Jf  months. 

"Fourteen  months  afterwards,  Mrs.  "W.  again  became  pregnant,  and 
was  again  affected  in  the  fourth  month  of  pregnancy  with  pruritus  followed 
by  pyrosis.  She  did  not  immediately  resort  to  smoking,  from  the  dislike 
of  this  habit,  until  the  evil  increased,  when  the  smoking  of  one  cigar  again 
rendered  her  perfectly  comfortable." 

No  local  application  has  acquired  a  more  universal  popularity  in  the 
treatment  of  pruritus  vulvae  than  solutions  of  corrosive  sublimate.  The 
following  formula  is  a  good  one  of  its  kind : — 

fy.  Hydrarg.  bichloridi,  3SS- 

Tr.  opii,  l\. 

Aquae,  §vij. — M. 
S.  For  external  use  only. 

Should  eczema  or  lichen  have  produced  inflammatory  action  in  the  skin 
and  subcutaneous  areolar  tissue,  poultices,  etc.,  should  be  employed,  as  if 
local  inflammation  were  the  cause  of  the  affection. 

"While  these  palliative  and  curative  means  are  being  adopted,  sleep 
should  be  secured  by  preparations  of  opium,  or  one  of  its  substitutes, 

1  N.  0.  Med.  and  Surg.  Journal,  Nov.  1866. 

2  Tribune  Med.,  Jan.  31,  1869  ;  Wiener  Med.  Wochenschrift,  No.  22,  1869. 


144  DISEASES    OF    THE    VULVA. 

codeine,  chloral,  hyoscyamus,  or  chlorodyne.  At  the  same  time  the 
general  state  of  the  patient  should  be  improved  by  vegetable  and  mineral 
tonics,  good  food,  and  fresh  air.  In  some  cases  more  benefit  will  arise 
from  the  use  of  iron,  the  mineral  acids,  and  sea-bathing,  than  from  any 
other  means. 

In  certain  cases  dependent  upon  chronic  vaginitis,  or  chronic  endo- 
metritis which  has  resulted  in  vaginitis,  the  disorder  will  be  found  to  be 
rather  "pruritus  vagime"  than  "pruritus  vulvae, "  and  under  these  circum- 
stances the  severity  of  the  local  and  general  disturbance  may  be  very  great. 
In  such  cases  I  have  found  great  benefit  from  the  frequent  use  of  copious 
vaginal  injections  of  warm  infusion  of  bran.  The  patient,  in  the  semi- 
recumbent  posture,  with  the  nates  over  a  tub  containing  three  or  four 
quarts  of  this,  with  from  six  to  eight  drachms  of  laudanum,  and  one  to 
two  drachms  of  acetate  of  lead  dissolved  in  it,  should  inject  the  vagina 
freely  for  from  ten  to  fifteen  minutes,  and  this  should  be  repeated  four  or 
five  times  a  day.  After  a  short  time  the  soothing  and  alterative  influence 
which  it  exerts  will  show  itself  so  decidedly  that  less  assiduous  attention 
to  the  disorder  will  be  demanded. 

In  the  same  way  infusion  of  tobacco  and  solutions  containing  borax,  lead, 
alum,  zinc,  or  carbolic  acid  will  be  found  to  be  very  valuable  remedies. 
They  should  be  used  very  freely,  and  after  previous  cleansing  of  the  vagina 
by  pure  water.  One  great  difficulty  in  the  treatment  of  the  disease  con- 
sists of  the  inefficient  manner  in  which  vaginal  injections  are  practised  by 
patients.  This  should  be  guarded  against  by  explicit  directions,  and  the 
use  of  the  means  suggested  hereafter  in  connection  with  that  subject. 

The  following  prescriptions  have  obtained  a  reputation  for  the  treatment 
of  pruritus ;  and  I  know  by  experience  that  they  deserve  it : — 

B-  Chloroformi,  5J- 

01.  ainygdalarum,  ^j- — M. 
S.  Apply  to  vulva  and  outlet  of  vagina. 

ty.  Acidi  hydrocyan.  dil.  3'j- 

Plumbi  diacetati,  9j. 

Olei  cacao,  Jij. — M. 
S.  Apply  after  washing  with  cold  water. 

B-  Lotionis  nigri,  Oj. 

Sodae  biborat.  ^j- 

Morphiae  sulphat.  gr.  v. — M. 
S.  Apply  after  bathing  the  part. 

B»  Acidi  tannici,  gr.  c. 
Belladonnas  ext.  gr.  x. 
Butyr.  cacao,  q.  s. 
M.  et  ft.  supposit.  vag.  xx. 
S.  Let  the  patient  place  one  in  contact  with  the  cervix  uteri,  every  night,  after 
thoroughly  syringing  the  vagina. 


HYPERESTHESIA    OF    THE    VULVA.  145 

"Where  diabetes  exists  as  a  cause,  the  patient  should  bathe  the  parts  after 
urination,  and  be  instructed  to  keep  the  vulva  thoroughly  covered  and 
protected  by  one  of  the  ointments  already  mentioned. 

Where  the  pediculus  pubis  is  found  to  exist,  mild  mercurial  ointment 
should  be  applied  ;  and  for  the  acarus  scabiei,  sulphur  ointment  will  be 
found  sufficient  as  a  parasiticide. 

When  the  itching  is  located  in  the  skin  of  the  mons  veneris  and  sur- 
rounding parts,  rubbing  it  freely  with  a  moist  stick  of  nitrate  of  silver  is 
often  of  great  service. 

The  following  prescription  I  have  never  employed,  but  it  is  highly  rec- 
ommended by  good  authority  : — 

R.  Zinci  sulpho-carbolat.  3j. 
Aquae  destillat.  j§ij. 
S.  After  careful  bathing  use  as  a  wash  once  or  twice  a  day. 

Where  short,  bristly  hairs  are  found  growing  from  the  inner  or  mucous 
surface  of  the  labia  majora,  great  relief  follows  depilation.  Each  hair 
should  be  seized  by  forceps,  the  operator  using  a  magnifying  glass,  and 
jerked  from  its  place. 

Dr.  Stevens,  of  Cincinnati,  reports  excellent  results  from  the  use  of  undi- 
luted sulphurous  acid  as  a  wash  applied  freely  to  the  vulva.  He  declares 
that  prompt  relief  is  in  that  way  attainable. 

Hyperesthesia  of  the  Vulva. 

Definition The  disease  which  I  proceed  to  describe  under  this  name, 

although  to  all  appearances  one  of  trivial  character,  really  constitutes,  on 
account  of  its  excessive  obstinacy  and  the  great  influence  which  it  obtains 
over  the  mind  of  the  patient,  a  malady  of  a  great,  deal  of  importance.  It 
consists  in  an  excessive  sensibility  of  the  nerves  supplying  the  mucous 
membrane  of  some  portion  of  the  vulva  ;  sometimes  the  area  of  tenderness 
is  confined  to  the  vestibule,  at  other  times  to  one  labium  minus,  at  others 
to  the  meatus  urinarius ;  and  again  a  number  of  these  parts  may  be 
simultaneously  affected.  It  is  a  condition  of  the  vulva  closely  resembling 
that  hyperaBsthetic  state  of  the  remains  of  the  hymen  which  constitutes  one 
form  of  vaginismus.  In  two  cases  I  have  seen  the  whole  surface  of  the 
vulva,  except  the  labia  majora,  affected  by  an  excessive  sensibility  which 
extended  along  the  urethra. 

Frequency This   disorder,  although  fortunately  not  very  frequent,  is 

by  no  means  very  rare.  So  commonly  is  it  met  with  at  least,  that  it  be- 
comes a  matter  of  surprise  that  it  has  not  been  more  generally  and  fully 
described. 

Pathology It  is  not  a  true  neuralgia,  but  an  abnormal  sensitiveness  ; 

"  a  plus  state  of  excitability"  in  the  diseased  nerves.  No  inflammatory 
action  affects  the  tender  surface,  no  pruritus  attends  the  condition,  and 
10 


146  DISEASES    OF    THE    VULVA. 

physical  examination  reveals  nothing  except  occasional  spots  of  erythema- 
tous redness  scattered  here  and  there.  The  nerve  state  appears  identical 
with  that  which  sometimes  develops  in  the  scalp,  and  on  parts  of  the 
cutaneous  surface.  The  slightest  friction  excites  intolerable  pain  and 
nervousness  ;  even  a  cold  and  unexpected  current  of  air  produces  discom- 
fort ;  and  any  degree  of  pressure  is  absolutely  intolerable.  For  this  reason 
sexual  intercourse  becomes  a  source  of  great  discomfort,  even  when  the 
ostium  vaginae  is  large  and  free  from  disease.  It  is  this  difficulty  which 
generally  first  causes  the  patient  to  apply  to  a  physician  for  relief. 

Causes The  predisposing  causes  appear  to  be  the  period  of  life  near 

or  at  the  menopause,  the  hysterical  diathesis,  or  a  morbid  mental  state 
characterized  by  tendency  to  depression  of  spirits.  As  exciting  causes  I 
have  found  chronic  vulvitis  and  irritable  urethral  tumors  to  exist  in  some 
cases,  but  in  others  no  cause  whatever  has  been  apparent. 

Symptoms I  have  said  so  much  on  this  subject,  under  the  head  of  de- 
finition, that  I  have  little  more  to  add.  The  patient  applies  for  relief 
because  the  act  of  sexual  intercourse  is  painful,  and  because  in  the  sensi- 
tive spot  there  is  always  a  degree  of  discomfort,  which  is  increased  by 
bathing  the  part,  or  even  by  the  friction  incident  to  walking.  Upon 
questioning  her,  it  will  be  observed  that  her  mind  is  disproportionately 
disturbed  and  depressed  by  this.  In  some  cases  it  seems  to  absorb  all  the 
thoughts,  and  to  produce  a  state  bordering  upon  monomania. 

Differentiation.  —  It  should  be  distinguished  from  irritable  urethral 
tumor  and  vaginismus,  which  will  be  readily  accomplished  by  inspection 
and  touch. 

Treatment. — The  treatment  of  this  condition  is  most  unsatisfactory.  I 
have  met  with  a  number  of  cases  of  marked  character,  and  in  not  one  was 
complete  relief  given  by  treatment.  Whether  they  subsequently  recovered 
I  cannot  say,  but  they  certainly  were  not  cured  while  under  my  observa- 
tion. In  one  case,  which  I  saw  with  Dr.  Metcalfe,  the  sensitive  area  was 
the  vestibule,  and  to  this  we  applied  nitric  acid  so  as  to  destroy  the  mucous 
membrane  completely  and  followed  this  up  by  local  sedatives,  but  to  no 
purpose.  In  another,  which  I  attended  with  Dr.  Sims,  he  removed  por- 
tions of  the  labia  minora  and  of  the  vulvar  mucous  membrane,  without  suc- 
cess. In  another  case  I  dissected  off  all  the  sensitive  tissue,  which  was 
quite  extensive.  This  patient,  the  wife  of  a  clergyman,  left  me  well,  and 
was  greatly  rejoiced  ;  but,  in  six  months,  I  received  a  letter  from  her  de- 
claring that  she  was  worse  than  before  the  operation.  The  treatment 
which  I  would  recommend  from  my  experience  is  this  :  to  send  the  patient 
away  from  home  where,  in  addition  to  enjoying  change  of  air,  scene,  and 
surroundings,  she  would  live  absque  marito  :  to  put  her  upon  the  use  of 
general  tonic.-,  as  arsenic,  strychnine,  quinine,  and  iron  ;  and  after  having 
cured  any  local  exciting  disease,  like  vulvitis  or  urethral  vegetations  or 
tumors,  to  make  frequent  ablutions  with   warm  water  and  apply  sedative 


IRRITABLE    URETHRAL    CARUNCLE.  147 

and  calmative  substances  in  the  form  of  lotions  or  ointments.  As  examples 
of  these,  I  would  mention  opium  or  its  salts,  carbolic  acid,  chloroform, 
belladonna,  and  iodoform.  Sometimes  benefit  seems  to  result  from  strong 
solutions  of  alum,  tannin,  and  similar  agents. 

My  observation  of  the  results  of  caustics  and  the  knife  is  not  such  as  to 
inspire  me  with  confidence  in  them. 

Irritable  Urethral  Caruncle. 

This  affection  has,  likewise,  received  the  names  of  vascular  tumor,  and 
irritable  vascular  excrescence  of  the  urethra. 

Just  at  the  edges  of  the  meatus  urinarius,  and,  sometimes,  along  its 
walls  for  some  distance,  little  vascular  tumors  develop  themselves,  which 
render  this  canal  very  irritable,  and  in  this  way  produce  a  great  deal  of 
discomfort. 

Pathology According  to  Wedl1  they  consist  of  hypertrophied  papilla?, 

which,  as  they  enlarge,  are  accompanied  by  excessive  growth  of  areolar 
tissue.  They  are  extremely  vascular,  capillary  vessels  of  considerable  size 
being  found  within  them,  ramifying  in  transverse  sections,  very  much  like 
the  vasa  vorticosa  of  the  choroid.  Dr.  Reid,2  of  Edinburgh,  declares  that 
they  are  richly  supplied  with  nervous  filaments.  These  two  anatomical 
facts  account  for  two  corresponding  clinical  observations,  that  they  bleed 
very  freely  and  readily,  and  that  they  are  almost  as  sensitive  to  the  touch 
as  a  neuroma.  Savage  styles  these  curious  growths  "  pseudo-angiomata," 
and  asserts  that  within  them,  cystic  cavities,  probably  the  remains  of  ure- 
thral glands,  are  occasionally  found,  filled  with  mucus. 

Causes. — Of  the  etiology  of  this  affection  nothing  is  known.  It  develops 
in  the  young  and  old ;  the  married  and  single. 

Symptoms. — The  patient  complains  of  pain  upon  sexual  intercourse,  in 
passing  urine,  in  walking,  and  upon  the  slightest  contact  of  the  clothing. 
Sleep  is  disturbed  by  these  means,  and  by  the  increase  of  sensitiveness 
engendered  by  the  warmth  of  the  bed.  As  a  consequence,  she  becomes 
nervous,  hysterical,  and  greatly  depressed  in  spirits.  Her  whole  thoughts 
often  become  fixed  upon  this  one  painfully  absorbing  topic,  and  a  most 
wretched  mental  state  is  at  times  produced.  Of  course  these  grave  results 
occur  only  in  very  aggravated  cases  ;  but,  even  in  minor  ones  they  are 
present  in  slight  degree. 

Dr.  T.  F.  Cock  informed  me  of  a  case  in  which  a  patient  became  so 
much  depressed  from  this  cause  that  she  committed  suicide,  and  I  have  a 
similar  statement  of  another  case  from  a  non-professional  source.  In  the 
latter,  the  time  had  been  appointed  for  removal  of  the  growth  when  the 
patient  destroyed  her  life.  I  should  be  sorry  to  leave  the  impression,  that 
mental  alienation  of  grave  character  is  likely  to  develop  from  these  little 

1  Pathological  Anatomy.  2  Simpson,  Diseases  of  Women,  p.  276. 


148  DISEASES    OF    THE    VULVA. 

growths  ;  it  is  not.  A  certain  degree  of  it  is  very  apt  to  be  met  with ; 
and,  in  rare  cases,  where  the  suffering  is  very  great,  it  sometimes  becomes 
excessive.  To  convey  some  idea  of  the  amount  of  pain  induced  by  urina- 
tion in  some  cases,  I  quote  the  following :  "  I  was  told  by  a  shepherd's 
wife,  who  had  one  of  these  sensitive  caruncles  at  the  orifice  of  the  urethra, 
that,  whenever  she  was  obliged  to  pass  water,  she  was  in  the  habit  of  going 
to  some  distance  away  from  her  cottage,  in  order  that  she  might  moan  and 
scream  unheard,  and  not  distress  her  family  with  the  sound  of  her  cries, 
so  intense  and  intolerable  was  the  suffering  which  at  such  times  she 
experienced."1 

Physical  Signs — The  patient  being  placed  upon  the  back  with  the 
thighs  flexed  and  the  knees  separated,  inspection  shows,  at  the  meatus  uri- 
narius,  a  florid,  vascular  growth,  varying  in  size  from  that  of  a  cherry- 
stone to  that  of  a  pigeon's  egg.  Scanzoni  declares  that  they  may  grow  to 
the  size  of  a  goose's  egg.  Sometimes,  instead  of  one,  quite  a  number  may 
be  found,  of  small  size,  extending  around  the  meatus  or  up  the  canal. 
"Where  the  canal  itself  is  invaded,  the  cases  are  always  very  difficult  of 
cure,  on  account  of  the  difficulty  in  reaching  the  morbid  developments. 

Differentiation. — There  are  but  two  conditions  with  which  I  have  ever 
known  the  disease  confounded.  One  is  prolapsus  urethrae  or  eversion  of 
the  mucous  membrane  of  the  canal ;  the  other  syphilitic  growths  of  warty 
character.  From  the  first  a  careful  examination  will  readily  distinguish 
it,  and  when  the  second  exists  similar  developments  will  be  found  upon 
other  parts  of  the  vulva.  Besides  neither  of  these  conditions  is  nearly  so 
annoying  and  painful  as  that  which  we  are  considering. 

Course  and  Duration. — It  is  impossible  to  say  how  long  these  growths 
will  continue  to  exist  when  not  interfered  with.  I  have  known  them 
last  for  years  without  continuing  to  develop,  but  retaining  a  small  size, 
and  being  always  excessively  sensitive  and  annoying. 

Prognosis In  case  a  single  large  caruncle  exist,  an  almost   positive 

promise  of  relief  may  be  held  out  from  its  removal ;  but  where  a  number 
of  small,  fungous,  warty  growths  surround  the  meatus  and  extend  up  the 
urethra,  cure  is  extremely  difficult,  for  no  sooner  are  they  removed  tlian 
the  morbid  process  of  development  rapidly  produces  more.  Another  dis- 
couraging feature  of  these  cases  is  this,  a  nervous  hyperesthesia  is  engen- 
dered by  the  growth,  wrhich  lasts  long  after  its  removal.  It  behooves  the 
operator  in  such  cases  always  to  be  guarded  in  his  promises,  at  the  same 
time  that  he  urges  interference  as  the  only  hope  for  relief  in  the  present, 
and  safety  from  increased  trouble  in  the  future. 

Treatment. — Before  operating  the  patient  should  be  thoroughly  anaesthe- 
tized and  placed  upon  the  back,  with  the  thighs  flexed  and  the  knees 
widely  separated.     The  labia  being  then  separated  by  an  assistant  on  each 

1  Simpson,  op.  cit. 


IRRITABLE    URETHRAL    CARUNCLE. 


149 


side,  the  tumor  should  be  seized  near  its  base  by  forceps,  pulled  towards 
the  operator,  and  its  attachment  cut  by  scissors.  Very  free  hemorrhage 
may  occur.  To  control  this,  the  raw  surface  should  be  wiped  dry  and 
thoroughly  touched  with  fuming  nitric  acid,  a  stick  of  nitrate  of  silver,  or 
the  actual  cautery. 

This  operation  may  be  very  nicely  performed  by  galvano-cautery,  if  an 
instrument  be  attainable.  By  this  means  not  only  is  hemorrhage  pre- 
vented, the  base  is  also  thoroughly  cauterized,  which  is  a  great  safeguard 
against  return  of  the  growth. 

Where  the  urethra  has  been  invaded  it  should  be  thoroughly  stretched 
by  little  retractors  introduced  within  it,  and  held  by  assistants,  and  the 
growths  thus  exposed  be  cut  off  by  scissors,  or  scraped  from  their  attach- 
ments by  a  steel  curette.     After  removal,  their  bases  should  be  very  cau- 

Fig.  40. 


Paquelin's  Thermo-Cautery. 

The  apparatus  consists  of  a  hollow  handle,  insulated  with  wood,  to  protect  the  hands  from  the 
heat.  It  is  furnished  with  three  movable,  hollow,  platinum  cauteries  ;  into  these,  after  they  have 
been  heated  to  blackness  in  the  flame  of  a  spirit  lamp,  a  blast  of  benzine  vapor  is  introduced  by 
means  of  a  Richardson's  spray  bellows,  which  at  once  raises  them  to  and  maintains  them  at  a  state 
of  vivid  incandescence.  The  heat  thus  produced  can  be  kept  up  for  an  indefinite  time  by  slightly 
compressing  the  bellows  occasionally. 


tiously  touched  with  nitric  acid,  or,  what  is  still  better  as  preventive  of 
return,  the  actual  cautery.  A  few  years  ago  the  actual  cautery  was  an 
instrument  so  unmanageable  and  difficult  of  employment  that  it  was  rarely 
used  for  slight  operations.  Now,  thanks  to  the  genius  of  M.  Paquelin, 
whose  instrument  is  shown  above,  it  is  used  as  easily  as  the  stick  of  nitrate 
of  silver. 


150  DISEASES    OF    THE    VULVA. 

Urethral  Venous  Angioma. 

This  is  a  disease  affecting  the  urethro-vaginal  tubercle  or  anterior  half 
of  the  urethro-vaginal  septum.  It  sometimes  attains  large  size,  and  pro- 
jects between  the  labia.  From  irritable  caruncle  or  vascular  excrescence 
it  can  be  differentiated  by  its  want  of  sensitiveness. 

It  appears,  says  Savage,1  to  be  due  to  venous  congestion,  analogous  to 
that  giving  rise  to  priapism. 

Its  treatment  is  identical  with  that  of  urethral  caruncle. 

Prolapsus  Urethrae. 

This  accident,  which  has  likewise  been  described  as  procidentia  and 
eversio  urethrae,  consists  of  prolapse  of  the  urethral  mucous  membrane, 
with  proliferation  of  the  underlying  connective  tissue.  It  is  not  commonly 
met  with,  but  at  times  produces  considerable  irritation  of  the  urethra  and 
bladder,  and  leads  to  an  erroneous  diagnosis  of  irritable  caruncle.  I  have 
met  with  it  only  in  adults  of  enfeebled  constitution  and  advanced  age; 
but  Guersant,  in  the  Revue  de  Therapeutique,  declares  that  he  has  seen 
fifteen  cases  in  little  girls  between  two  and  twelve  years  of  age.  Diag- 
nosis is  easy.  A  roseate  projection  encircles  the  meatus,  which  is  sensi- 
tive and  liable  to  bleed.  The  only  diseases  with  which  it  could  be  con- 
founded are,  irritable  caruncle,  urethral  polypus,  and  venous  angioma. 
From  all  these  it  can  readily  be  differentiated  by  careful  examination, 
which  shows  that  it  entirely  surrounds  the  meatus,  while  they  do  so  only 
in  part.  The  extreme  sensitiveness  of  irritable  caruncle  is  not  a  differen- 
tial sign  which  can  be  relied  upon,  for  I  have  seen  prolapse  of  the  urethra 
develop  this  symptom  very  decidedly. 

It  may  for  some  time  exist  without  symptoms,  but  usually  soon  creates 
difficult  and  painful  micturition,  pruritus  vulvae,  and  leucorrh(jeal  discharge. 

Treatment The  simplest  method  of  treatment  is  to  seize  the  prolapsed 

circle  with  tooth-forceps,  the  patient  being  anaesthetized,  draw  it  down 
with  very  little  force,  and  cut  it  off  with  curved  scissors.  The  resulting 
hemorrhage  will  readily  be  controlled  by  applying  a  pledget  of  lint  or 
cotton,  saturated  with  a  solution  of  persulphate  of  iron,  one-third  of  the 
full  strength,  against  the  raw  surface,  and  making  pressure  by  the  finger 
for  some  minutes.  Should  it  be  deemed  necessary  to  continue  it  longer, 
this  may  be  done  by  a  T  bandage. 

If  great  vascularity  leads  to  fear  of  hemorrhage,  the  ingenious  method 
of  Sequin  may  be  adopted  with  advantage.  This  consists  in  introducing 
a  female  catheter  into  the  bladder,  and  ligating  the  prolapsed  part  to  it 
so  as  to  strangulate  it  entirely.  The  catheter  is  left  in  situ  until  released 
by  sloughing  off"  of  ths  ligated  part. 

1  Savage,  op.  cit. 


COCCYODYNIA.  151 

In  one  case  I  drew  down  the  prolapsed  tissue,  passed  a  double  silk 
ligature  through  its  base,  and  tied  the  two  halves.     The  cure  was  perfect. 

A  better  operation  than  either  of  these  would  be  encircling  the  pro- 
lapsed tissue,  which  should  be  well  drawn  down,  by  the  galvano-caustic 
wire,  removing  the  mass  in  this  way,  and  keeping  a  catheter  in  the  blad- 
der for  some  days  if  necessary. 

Should  obstinate  hemorrhage  follow  any  of  these  operations  upon  the 
urethra  or  vulva,  a  firm  vaginal  tampon  with  a  T  bandage  used  so  as  to 
press  its  lowest  portion  against  the  bleeding  surface  will  readily  control  it. 
The  former  presses  the  urethra  upwards  and  the  labia  outwards,  while  at 
the  same  time  it  gives  a  firm,  fixed  point,  against  which  direct  pressure 
by  a  T  bandage  and  compress  may  be  made.  It  possesses  more  real 
value  than  all  the  other  means,  usually  mentioned  for  the  control  of  such 
hemorrhages,  combined ;  such,  for  example,  as  Monsell's  salt,  the  actual 
cautery,  strong  acids,  etc.  The  vulva  is  so  exquisitely  sensitive  that  the 
patient  is  apt  to  rebel  against  these,  and  in  addition  they  often  fail  in 
accomplishing  the  result. 

Coccyodynia. 

Definition  and  Frequency This  affection  consists  in  a  morbid  state  of 

the  coccyx,  or  the  muscles  attached  to  it,  which  renders  their  contraction, 
and  the  consequent  movement  of  the  bone,  very  painful.  It  is  of  frequent 
occurrence,  numerous  cases  having  been  observed,  since  attention  has 
been  called  to  it,  by  practitioners  who  saw  it  previously  without  regarding 
it  as  a  special  disorder. 

History Coccyodynia  was  first  described,  in   1844,  by  the  late  Dr. 

Nott.  Under  the  name  of  neuralgia  of  the  coccyx  he  described  a  case 
which  fully  embodies  the  symptoms  and  treatment  of  the  affection  by  sur- 
gical resource.1 

Although  Dr.  Nott  gave  every  detail  with  which  we  are  now  familiar, 
as  to  the  symptomatology  and  treatment  of  this  affection,  the  subject  was 
nearly  forgotten  until  the  year  1861,  when  it  was  again  described,  almost 
simultaneously,  by  Simpson,  of  Scotland,  who  gave  it  its  name,2  and 
Scanzoni,  of  Germany.  We  have  in  this  another  instance,  of  which  so 
many  exist,  of  the  complete  oblivion  into  which  a  few  years  may  cast  a 
valuable  contribution  to  science.  Surely  in  such  a  case  he  who  revives 
what  is  forgotten  deserves  as  much  credit  as  he  who  originally  made  the 
discovery. 

Anatomy The  coccyx  serves  as  a  point  of  attachment  for  the  greater 

1  N.  0.  Med.  Journ.,  May,  1844. 

2  In  Prof.  Alexander  Simpson's  edition  of  Sir  James  Simpson's  posthumous 
volume  on  Diseases  of  Women,  the  name  coccygodynia  is  used.  In  his  Clinical 
Lectures,  published  in  Philadelphia,  1863,  the  name  which  I  here  employ 
appears. 


152  DISEASES    OP    THE    VULVA. 

and  lesser  sacro-sciatic  ligaments,  the  ischio-coccygei  muscles,  the  sphinc- 
ter ani,  levatores  ani,  and  some  of  the  fibres  of  the  glutei  muscles.  These 
are  thrown  into  activity  by  certain  movements,  as  rising  from  the  sitting 
into  the  standing  posture,  the  act  of  defecation,  etc.,  and  in  such  acts  the 
existence  of  the  disorder  which  we  are  considering  is  revealed. 

Pathology. — The  peculiar  pain  which  characterizes  this  disease  has, 
according  to  my  experience,  a  variety  of  causes;  I  have  removed  one 
coccyx  in  which  a  fracture  with  dislocation,  received  in  early  life,  which 
caused  it  to  jut  in  at  a  right  angle  to  the  sacrum,  was  its  source;  another 
in  which,  as  in  Dr.  Nott's  case,  just  recorded,  caries  existed;  while  in 
still  a  third  no  abnormal  condition  could  be  discovered.  In  such  cases  as 
the  last,  the  pain  which  characterizes  it  is  probably  due  to  a  hyper-sensi- 
tive state  of  the  fibrous  tissues  surrounding  the  coccyx,  or  of  that  making 
up  the  tendinous  expansions  of  the  muscles.  This  may  at  times  be,  as 
Prof.  Simpson  has  suggested,  of  rheumatic  character;  but  it  appears  to 
me  that  it  is  very  generally  a  neuralgic  state,  due  to  uterine  or  ovarian 
disease,  of  which  coccyodynia  is  a  frequent  consequence. 

As  a  rule,  so  long  as  the  bone  is  uninfluenced  by  contraction  of  the 
muscles  attached  to  it,  no  pain  is  experienced,  but  as  soon  as  contraction 
produces  motion  it  is  excited. 

Causes It  occurs  most  frequently  in  women  who  have  borne  children, 

but  it  is  by  no  means  confined  to  them.     I   have  on   two  occasions  met 
with  it  in  young,  unmarried  ladies,  and  Ilerschelman  reports  two  cases  in 
children  from  four  to  five  years  of  age. 
Its  chief  causes  are  the  following: — 

Blows  or  falls  upon  the  coccyx. 

Injuries  inflicted  by  parturition. 

The  influence  of  cold  and  exposure. 

Uterine  and  ovarian  disease. 

Horseback  exercise.1  (?) 
In  a  case  mentioned  by  Courty  the  patient  had  the  peculiar  habit  of 
sleeping  with  the  buttocks  uncovered,  and  the  sacrum  pressed  against  the 
wall.  In  nine  of  Scanzoni's  cases  the  condition  followed  parturition;  in 
five,  the  use  of  the  obstetric  forceps ;  and  in  two,  horseback  exercise  was 
the  only  cause  ascertainable. 

Symptoms The  patient,  upon  sitting  down,  rising,  making  any  effort, 

or  passing  feces  through  the  rectum,  experiences  severe  pain  over  the 
coccyx.  In  some  cases  this  is  so  severe  as  to  cause  the  greatest  dread  of 
sudden  or  violent  movement.  In  others,  the  patient  is  unable  to  sit,  on 
account  of  the  discomfort  caused  by  pressure  on  the  bone.  The  most  try- 
ing process  is  that  of  rising  from  a  low  seat,  and,  to  accomplish  this,  the 
sufferer  will  obtain  all  the  aid  that  is  practicable,  by  assistance  with  the 

*  Scanroni,  op.  cit. 


COCCYODYNIA.  153 

hands,  which  will  he  placed  as  auxiliary  supports  upon  the  edges  of  the 
chair  or  stool  upon  which  she  rests. 

Differentiation The  only  conditions  with  which  this  may  he  con- 
founded are  painful  hemorrhoids,  fissure  of  the  anus,  and  a  spasmodic 
condition  about  the  muscles  of  this  part,  due  to  ascarides  in  the  rectum. 
From  these  a  careful  and  thorough  physical  examination  will  always 
readily  distinguish  it. 

Prognosis Coccyodynia  often  lasts  for  years,  annoying  and  distressing 

the  patient,  but  never  to  any  degree  depreciating  her  health  or  constitu- 
tional state.  If  left  to  nature  it  may  wear  itself  out,  but  it  is  probable 
that  it  would  generally  remain  for  a  long  time  if  not  relieved  by  art. 

Treatment Before   any  plan  of  treatment   is   adopted,  care   must  be 

taken  to  discover  whether  the  disorder  is  secondary  to  uterine  disease  or 
anal  fissure.  If  it  be  so,  the  primary  disorders,  and  not  their  results, 
should  receive  attention. 

If  the  coccygeal  disease  be  primary,  blistering,  the  use  of  morphia  by 
the  hypodermic  method,  and  the  persistent  use  of  the  galvanic  current  will 
often  effect  a  cure.  While  they  are  being  tried,  the  use  of  iodoform  as 
a  rectal  suppository  may  be  with  advantage  employed  together  with  all 
general  means  calculated  to  improve  the  tone  of  the  nervous  system. 

Should  these  means  do  no  good,  and  the  patient's  condition  demand 
relief,  recourse  should  be  had  to  one  of  two  radical  methods  of  cure, 
section  of  the  diseased  muscles,  or  amputation  of  the  bone  to  which  they 
are  attached.  The  first,  placed  at  our  disposal  by  the  late  Prof.  Simpson, 
consists  in  severing  the  attachments  of  all  the  coccygeal  muscles ;  the 
second,  in  extirpating  the  coccyx  itself,  after  the  plan  of  Dr.  Nott. 

The  first  operation  may  be  performed  subcutaneously  by  an  ordinary 
tenotomy  knife.  This  is  passed  under  the  skin  at  the  lowest  point  of  the 
coccyx,  turned  fiat,  and  carried  up  between  the  skin  and  cellular  tissue 
until  its  point  reaches  the  sacro-coccygeal  junction.  Then  it  is  turned  so 
that  in  withdrawing  it  an  .incision  may  be  made  which  entirely  frees  the 
coccyx  from  muscular  attachments.  The  knife  is  then  introduced  on  the 
other  side  so  as  to  repeat  the  section  there.  As  is  usually  the  case  in 
subcutaneous  operations,  no  hemorrhage  occurs  unless  some  large  vessel 
be  injured.  I  have  resorted  to  this  procedure  but  once,  when  I  found  it 
exceedingly  difficult  of  accomplishment,  and  it  proved  an  entire  failure  in 
giving  relief. 

In  fat  women  subcutaneous  section  of  the  muscles  attached  to  the 
coccyx  is  by  no  means  so  easy  a  matter  as  one  would  suppose  who  has  not 
made  the  experiment.  Under  these  circumstances  the  operation  is  sim- 
plified and  rendered  more  certain  by  making  an  incision  down  upon  the 
coccyx,  lifting  the  exposed  extremity  of  this  bone  with  the  finger,  and 
then  with  a  pair  of  scissors  severing  the  muscles.     This  procedure  is  both 


154  THE    FEMALE    PERINEUM; 

easy  of  performance  and  certain  as  to  result ;  that  is,  supposing  that  it  is 
resorted  to  in  a  case  really  demanding  it. 

Should  detachment  of  the  muscles  fail,  as  it  will  do  if  the  bone  be 
diseased,  an  incision  should  be  made  over  the  coccyx,  the  bone  laid  bare 
by  severance  of  its  attachments,  and  the  whole  of  it  removed  by  a  pair  of 
bone  forceps,  or  disarticulated  by  the  knife  as  practised  by  Dr.  Nott  in 
the  case  already  mentioned.  By  one  of  these  procedures  cure  can  be  con- 
fidently promised,  and  as  neither  is  attended  by  danger,  our  resources  in 
this  affection  may  be  regarded  with  great  satisfaction. 

Many  slight  cases  of  coccyodynia  occur,  however,  which  pass  away 
witli  time  and  palliative  treatment.  The  gynecologist  should  take  care 
that  operation  is  not  resorted  to  too  early. 

Tumors  of  considerable  size  may  spring  from  the  external  organs  of 
generation.  Thus  we  may  have  tumors  resulting  from  hypertrophy  of  the 
clitoris,  or  of  the  nymphae,  lipoma  of  the  labia  majora,  and  cystic  tumors 
of  large  size  growing  by  a  pedicle  from  the  same  site.  Malignant  disease 
also  frequently  attacks  these  organs,  where  it  runs  its  usual  course  :  dif- 
fering in  nothing  from  its  career  in  other  locations. 

"We  have  now  considered  the  most  important  of  the  diseases  of  the 
vulva.  To  treat  of  them  all  would  be  to  devote  a  larger  space  to  the 
subject  than  a  work  of  this  character  could  afford.  Certain  important 
pathological  conditions  of  the  hymen  would  be  treated  of  here  were  it  not 
that  they  will  receive  notice  under  the  head  of  retention  of  menstrual 
blood. 

I  have  usually  considered  in  this  connection  rupture  of  the  perineum, 
but  as  a  very  obvious  advantage,  which  I  feel  sure  the  reader  will  appre- 
ciate, attends  having  that  subject  succeed  prolapse  of  the  vagina,  bladder, 
and  rectum,  I  have  transferred  it. 


CHAPTER  IX. 

THE  FEMALE  PERINEUM;  ITS  ANATOMY,  PHYSIOLOGY,  AND 
PATHOLOGY. 

A  great  deal  of  the  diversity  of  opinion  concerning  the  propriety  of 
the  repair  of  the  ruptured  perineum,  as  well  as  of  the  difficulty  attending 
the  comprehension  and  performance  of  the  operation,  is,  I  think,  due  to 
an  incorrect  understanding  of  the  anatomy  of  this  part.  While  the 
anatomy  of  the  male  perineum  has  been  conscientiously  studied,  that  of 
the  female  has  been  singularly  neglected,  and  this  neglect  has  reflected  a 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY.  155 

decided  influence  upon   the  knowledge  of  its  physiology,  pathology,  and 
surgery. 

The  conventional  method  of  dealing  with  the  anatomy  of  the  female 
perineum  is  to  pronounce  it  the  floor  of  the  pelvis ;  the  space  extending 
from  the  inferior  commissure  of  the  vulva  to  the  anus,  and  composed  of 
skin,  cellular  tissue,  aponeurotic  union  of  muscles,  and  the  mucous  mem- 
brane of  the  vagina.  Tyler  Smith  begins  his  remarks  upon  this  subject 
with  these  words,  "  To  the  obstetrician  the  anatomy  of  this  part  is  matter 
of  great  interest,"  and  yet  he  gives  such  a  description  of  it  as  I  have  stated 
above,  and  represents  it  by  an  illustration  showing  the  union  of  the 
sphincters  of  the  anus  and  vagina,  etc.  Playfair,  in  his  late  excellent 
work,  dismisses  the  subject,  which  he  pronounces  one  "of  great  obstetric 
interest,"  with  less  than  eight  lines,  just  three  more  than  Leishman  has 
allotted  to  it,  and  four  more  than  it  receives  in  Meadows'  Manual  of 
Midwifery. 

Upon  such  topics  French  writers  are  usually  quite  minute  and  full ;  but 
Cazeaux  deals  with  the  female  perineum,  in  his  "  Traite  de  l'art  des 
Accouchements,"  in  three  lines  and  a  half,  and  Joulin  does  not  mention  it. 

A  few  words  now  as  to  some  of  our  own  authors.  Meigs,  who  describes 
the  fourchette  quite  at  length,  does  not  describe  the  perineum  at  all,  nor 
is  any  mention  made  of  its  anatomy  by  Bedford,  Byford,  or  Miller. 

Obstetric  writers  may  defend  this  omission  by  the  assertion  that  they 
do  not  write  of  anatomy  but  of  obstetrics,  and  that  the  student  should 
come  to  them  informed  upon  this  subject.  Let  us,  then,  turn  to  the 
writers  on  anatomy  upon  whom  our  students  at  present  rely.  Cruveilhier, 
one  of  the  most  accurate  and  exhaustive  writers  upon  gross  anatomy,  after 
describing  quite  fully  all  the  external  organs  of  generation,  limits  his 
remarks  upon  the  female  perineum  to  an  enumeration  of  its  muscles  and 
fasciae,  saying  not  one  word  of  its  functions,  its  shape,  or  its  important 
relation  to  the  pelvic  viscera.  Wilson  and  Gray,  after  enumerating  the 
organs  of  generation  in  the  woman,  say  nothing  of  the  perineum.  But 
Holden1  promises  better  things.  On  the  middle  of  a  page,  in  large  letters, 
appear  the  words,  "The  Dissection  of  the  Female  Perineum;"  then 
follows  a  study  of  all  the  external  organs  of  generation,  and  nowhere 
appears  one  word  about  the  perineum  which  he  started  out  to  dissect, 
except  an  allusion  to  its  vessels  ;  and  for  these  the  reader  is  referred  to 
the  male  perineum. 

Even  if  the  plea  which  I  have  mentioned  were  available  for  obstet- 
rical writers,  it  would  not  be  so  for  those  upon  gynecology,  and  yet  in  not 
one  systematic  treatise  does  any  description  of  this  organ  appear,  except 
in  the  last  edition  of  my  own,  and  that  is,  I  regret  to  say,  very  imper- 
fect indeed.     A  vast  deal  is  said  about  the  causes  of  rupture  and  methods 

»  Holden's  Manual,  2d  Ed.,  p.  378. 


156 


TI1E    FEMALE    PERINEUM; 


of  cure,  but  nothing  about  the  mechanics,  the  physiology,  the  philosophy, 
if  I  might  be  allowed  the  phrase,  of  this  important  organ,  which  is  calcu- 
lated to  make  the  student  otherwise  than  superficial  with  reference  to  the 
subject. 

So  far  as  my  knowledge  extends,  we  owe  to  Dr.  Savage,  of  London, 
the  demonstration  of  the  fact  that  the  perineum  or  perineal  body  is,  in  the 
female,  a  triangular  wedge  composed  of  fascia  and  areolar  tissue,  which 
fills  the  space  intervening  between  the  backward  curve  of  the  rectum  and 
the  forward  curve  of  the  vagina.  Long  before  his  writing,  sections  of 
frozen  bodies  had  been  made,  showing  this  anatomical  fact;  but  he,  I  be- 
lieve, first  named  this  triangle  the  "perineal  body"  and  drew  our  atten- 
tion to  its  significance  and  uses. 

The  diagram  ordinarily  employed  to  convey  to  the  student  an  idea  of 
the  anatomy  of  the  perineum  and  the  relations  of  the  pelvic  organs  of  the 
female  is  that  represented  in  Fig.  41. 

Fig.  41. 


Diagram  ordinarily  used  for  representing  the  perineum. 


This  certainly  portrays  a  state  of  things  which  never  exists,  unless  arti- 
ficially produced,  and  distorts  the  reality  to  sucji  an  extent  as  to  be  pro- 
ductive of  absolute  evil,  yet  this  is  the  diagram  employed  by  Gray,  Wil- 
son, and  many  others,  and  even  to-day  it  is  quite  commonly  copied  into 
works  dealing  with  this  subject  in  a  special  manner. 

It  is,  I  think,  incumbent  uj>on  the  obstetrical  and  gynecological  writer 
to  give  to  the  student  a  correct  idea  of  the  perineum.     It  appears  to  me 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY.  lf>7 

that  the  anatomy  and  uses  of  a  part  should  be  simultaneously  deseribed,  if 
any  practical  utility  is  to  arise  from  the  description.  Present  to  the  stu- 
dent a  hypothetical,  supposititious  diagram  of  the  female  perineum — such 
as  that  seen  in  Fig.  41 — and  one  can  readily  look  with  charity  upon  his 
regarding  it  as  a  part  of  little  importance,  and  pardon  the  young  practi- 
tioner who  talks  flippantly  about  the  triviality  of  its  rupture,  and  is  apa- 
thetic at  the  bedside  as  to  prevention  of  the  accident. 

In  the  living  and,  indeed,  in  the  dead  body,  the  vagina  never  gapes,  as 
represented  in  this  diagram,  and  never  so  distorts  itself  unless  distended 
by  some  foreign  body  which  separates  wall  from  wall.  It  no  more  stands 
distended  without  some  such  influence  than  the  urethra  does  when  undis- 
tended  by  a  sound  or  catheter.  The  normal  vagina  is  a  collapsed  canal, 
and  its  anterior  wall  rests  directly  upon  the  posterior,  and  is  sustained  by 
it.  The  gentle  passage  of  a  small  cylindrical  speculum,  the  patient  lying 
upon  her  back,  or  of  a  small  Sims'  speculum  as  she  lies  upon  the  side, 
will   make   this   fact   quite   evident. 

To  the  finger  gently  passed  up  it  is  *IG*  *"• 

made  equally  apparent. 

Henle  has  made  a  study  of  the 
vagina  by  transverse  section,  and 
represents  it  by  the  following  dia- 
gram : — 

Here   the   anterior  and    posterior 

,.,.,,  Transverse  section  of  vagina  :  a,  anterior 

walls    are    seen    lying   directly  and  wail  ;p,  posterior  wail  (Henie). 

closely  in  contact. 

Fig.  43  represents  my  idea  of  the  true  relations  of  the  vagina,  bladder, 
uterus,  rectum,  and  perineum  to  each  other.  At  first  sight  it  resembles 
closely  Dr.  Savage's  diagram,  but  examination  will  show  that  it  differs 
materially  from  it  in  these  respects — the  uterus  is  lower  in  the  pelvis, 
more  inclined  forwards,  and  the  vagina,  instead  of  consisting  of  a  canal 
with  a  single  curve  from  behind  forwards,  presents  a  double  curve :  first, 
a  decided  one,  from  behind  forwards,  and  second,  a  very  slight  one,  from 
above  downwards  and  backwards.  It  is  the  result  of  careful  observation 
at  the  bedside  for  years,  with  special  reference  to  this  point,  and  I  cannot 
doubt  that  every  one  examining  upon  the  living  subject  with  reference  to 
the  position  of  uterus,  bladder,  and  rectum,  and  the  shape  and  direction 
of  the  vaginal  canal  which  it  portrays,  must  admit  its  accuracy.  One 
thus  examining  is  apt  to  regard  the  perineal  body  as  exaggerated ;  but 
the  prominence  given  to  this  is  fully  endorsed  by  Savage,  and  it  must  be 
borne  in  mind  that  this  represents  a  perfect  and  typical  organ,  unimpaired, 
as  it  so  often  is,  by  influences  which  will  soon  be  considered. 

Here  the  perineum  is  represented  in  all  its  importance  of  function  and 
essential  bearing  upon  the  maintenance  of  a  proper  relation  of  surrounding 
parts.     Instead  of  appearing  as  a  flat  surface  consisting  of  skin,  areolar 


158  THE    FEMALE    PERINEUM; 

tissue,  and  tendinous  expansion  of  muscles  filling  the  space  intervening 
between  the  anus  and  vulva,  it  is  seen  as  the  "perineal  body."  Triangu- 
lar in  shape,  composed  of  strong  and  elastic  connective  tissue,  it  is  bounded 
upon  its  superficial  face  by  the  plane  ordinarily  described  as  the  female 

Fig.  43. 


Normal  relation  of  the  pelvic  viscera. 

perineum.  It  is  a  concavo-convex  triangle.  Its  anterior  side,  very 
slightly  convex,  sustains  the  inferior  wall  of  the  vagina,  while  its  posterior 
side,  decidedly  concave,  supports  the  anterior  wall  of  the  rectum,  which 
naturally  arches  forwards  to  fill  its  concavity,  and  prevents  its  prolapsing 
into  the  vagina  and  out  of  the  vulva. 

At  its  upper  portion,  the  vagina,  it  will  be  observed  by  reference  to  the 
diagram,  forms  a  depression  which  receives  the  cervix  uteri  which  rests 
within  it,  impinges  upon  the  rectum,  and  is  to  a  certain  extent  sustained 
by  the  shelf-like  action  of  the  tissue  at  the  junction  of  the  upper  and  lower 
vaginal  curves.  All  this  is  fact,  not  theory,  and  all  of  it  can  be  verified 
at  the  bedside  by  an  unbiased  investigator. 

If  the  perineal  body  just  described  be  regarded  merely  from  a  mechani- 
cal point  of  view,  as  an  inactive  mass  of  tissue,  its  influence  in  the  co- 
ordination of  pelvic  support  may  well  be  doubted.  Let  it  be  remembered 
that  it  rests  inferiorly  upon  a  set  of  muscles  whose  union  occurs  at  the 
space  between  the  anus  and  vulva.  The  contraction  of  these  throws  the 
j>erineal  body  forwards  and  upwards,  presses  it  against  the  anterior  wall 
of  the  vagina,  and  thus  makes  of  it  an  active  agent  in  giving  support.     In 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY.  159 

some  cases  this  action  is  so  strong  as  to  become  abnormal  and  to  cause 
dyspareunia,  or  to  render   coition  entirely  impracticable.     So  marked  is 

this  at  times  that  the  perineal   body  has  to  be  cut  through  by  the  knife 
to  overcome  the  difficulty. 

AVe  are  now  prepared  to  appreciate  the  functions  of  the  female  perineum 
or  perineal  body  ;  for  I  feel  that  the  whole  triangle  must  be  described  as 
the  female  perineum,  if  we  ever  intend  to  inculcate  true,  rational,  and 
reliable  precepts  as  to  management  of  this  part  during  labor,  and  in  refer- 
ence to  uterine  displacements.  Its  functions  are  the  following:  1st,  it 
sustains  the  anterior  wall  of  the  rectum,  and  prevents  a  prolapse  of  this, 
which  would  inevitably  drag  downwards  the  upper  vaginal  concavity, 
and  with  it  the  cervix  uteri,  and  destroy  the  equilibrium  of  the  uterus ; 
2d,  it  sustains  the  posterior  vaginal  wall,  and  prevents  a  prolapse  of  this, 
which  would  allow  of  rectocele ;  3d,  upon  the  posterior  vaginal  wall  rests 
the  anterior,  upon  this  the  bladder,  and  against  the  bladder  the  uterus ; 
all  of  which  depend  in  great  degree  for  support  upon  the  perineal  body  ; 
4th,  it  preserves  a  proper  line  of  projection  of  the  contents  of  bladder  and 
rectum,  and  thus  prevents  the  occurrence  of  tenesmus,  a  frequent  cause  of 
pelvic  displacements. 

Remove  this  triangle,  and  the  relations  of  the  pelvic  viscera  are  liable 
to  grave  distortion  ;  as  the  removal  of  the  keystone  of  an  arch  of  masonry 
would  effect  the  same  result  in  the  structure  which  it  supports.  The 
change  is  not  immediate  or  so  striking,  for  there  we  deal  with  inelastic 
and  brittle  substances,  here  with  elastic  and  resilient  ones ;  there  with 
parts  unattached  to  outside  supports,  here  with  those  attached  through  the 
areolar  tissue  of  the  pelvis  to  its  bony  walls.  Let  me  show  the  keystone 
action  of  the  perineum  by  means  of  two  schematic  diagrams,  which  con- 
siderably exaggerate  its  dimensions. 

The  triangle  in  black  in  Fig.  44  represents  the  perineal  body  in  exag- 
gerated form,  and  shows  its  action  as  the  keystone  of  an  arch,  the  sides  of 
which  are  made  up  of  the  anterior  rectal  and  posterior  vaginal  walls  which 
rest  upon  it  and  are  sustained  by  it.  Fig.  45  shows  the  effect  of  removal 
of  this.  Now  no  longer  do  the  parts  which  rest  against  it  receive  support, 
and  their  immediate  tendency  is  to  fall  downwards  and  outwards.  I  now 
remove  these  exaggerated  diagrams  and  show  the  effect  of  destruction  of 
the  perineal  body  by  others. 

As  the  posterior  vaginal  wall  prolapses,  it  is  followed  by  the  anterior  rectal 
wail ;  this  effaces  the  superior  vaginal  depression  and  drags  directly  upon 
the  cervix  uteri  which  descends  likewise.  As  the  anterior  wall  descends, 
it  is  followed  by  the  posterior  wall  of  the  bladder,  this  to  a  certain  extent 
by  the  whole  organ,  and  this,  being  attached  to  the  uterus,  by  it  likewise. 

Previous  to  the  establishment  of  this  abnormal  relation  of  the  pelvic 
viscera  to  each  other,  the  bladder  was,  by  its  apposition  with  the  uterus, 


160 


THE    FEMALE    PERINEUM; 


a  means  of  anterior  support  to  it.     Now  it  not  only  ceases  to  perform  this 
useful  function,  but  becomes  an  absolute  and  direct  tractor  upon  it. 

Fig.  44. 


Schematic  diagram  of  perineal  body. 
Fig.  45. 


The  same,  perineal  body  removed. 


It  may  be  objected   that  the  keystone  in   this  case  is  an  inverted  one, 
and    that   therefore  the  comparison  does  not  hold  good.     But  this  is  not  a 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY.  161 

valid  criticism,  for  the  inverted  keystone  is  attached  above,  and  therefore 
has  an  action  which  it  would  not  otherwise  possess. 

Fig.  46. 


The  perineal  body  destroyed,  the  rectal  wall  descends 
Fig.  47. 


11 


The  perineal  body  destroyed,  both  rectal  and  vesical  -walls  descend. 


162 


THE    FEMALE    PERINEUM; 


I  now  proceed  to  point  out  another  mechanical  principle  involved  in  the 
support  of  the  pelvic  viscera  and  afforded  hy  the  anatomical  arrangement 
of  these  parts.  An  examination  of  Fig.  43  will  show  that  the  posterior 
vaginal  wall  is  decidedly  concave  in  its  upper  half,  and  very  slightly  con 
vex  in  its  lower.  Let  us  examine  first  the  mechanism  of  the  upper  half, 
and  then  of  the  lower.  Take  a  strip  of  steel  or  whalebone  (Fig.  48),  put 
one  end  (A)  upon  a  table,  and  giving  it  the  shape  of  the  letter  C,  make 
pressure  upon  its  upper  end  B,  and  the  elastic  band  will  always  yield  in 
one  direction — towards  its  convex  surface — in  the  direction  shown  by  the 
arrows. 

Fig.  48.  Fig.  49. 


wHtt~~^^ 


An  elastic  rod  when  bent  yields  towards 
its  convex  surface. 


An  elastic  rod  with  double  carves  yields  in 
opposite  directions. 


Now  change  the  shape  of  the  elastic  strip,  so  as  to  give  its  lower  half  a 
slight  anterior  curve  in  a  direction  opposite  to  that  of  the  upper,  and  make 
pressure  as  before.  The  upper  half  will  yield  towards  its  convex  surface, 
in  the  line  of  the  arrows  (Fig.  49) ;  but  not  so  the  lower.  This  will  yield 
towards  its  convex  surface  and  in  an  opposite  direction. 

Now  apply  this  to  the  posterior  vaginal  wall  under  the  influence  of 
pressure.  The  upper  concave  portion  will  yield  towards  the  rectum,  and 
receive  support  from  it  and  other  structures  resting  in  the  hollow  of  the 
sacrum.  The  lower,  slightly  convex  portion  will  tend  to  fall  forwards, 
and,  if  the  pressure  be  exaggerated,  downwards.  But  in  a  normal  state  of 
the  parts,  the  anterior  vaginal  wall  and  bladder  arrest  this  tendency  and 
the  posterior  wall  is  supported. 

Let  us  carry  this  a  little  further  and  see  what  the  effect  of  destruction 
of  the  perineal  body  would  be.     The  condition  shown  in  Fig.  49  is  then 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY. 


163 


greatly  exaggerated,  an  absolute  S  being  created,  and  tin;  lower  portion 
of  that  being  without  support  from  the  bladder,  which  is  no  longer  in  con- 
tact with  it,  prolapse  becomes  almost  inevitable.  Fig.  50  will  demon- 
strate this. 

lint  it  must  not  be  supposed  that  gravitation  is  the  only  influence  which, 
under  these  circumstances,  disturbs  the  relations  of  the  pelvic  viscera. 
Two  other  influences  add  themselves  to  those  just  mentioned  to  still 
farther  force  downwards  the  anterior  and  posterior  vaginal  walls.  Pro- 
lapse of  bladder  and  rectum  distort  the  line  of  extrusion  of  the  contents  of 
these  viscera,  and  thus  to  mere  traction  upon  the  parts  above,  direct 
expulsive  power  is  brought  to  bear. 

And  now,   too,   the  uterus,   dragged  ^IC-  ''"• 

downwards  from  its  position  by  the 
heavy  vagina  and  still  heavier  blad- 
der, adds  its  weight  as  an  influence 
calculated  to  increase  the  existing 
tendency  to  prolapse  of  all  the  vis- 
cera of  the  pelvis.  It  falls  down- 
wards, forwards,  or  backwards,  offer- 
ing an  instance  of  some  one  of  those 
uterine  displacements  which  we  so 
often  meet  with,  and  which  cause 
practitioners  so  much  annoyance  and 
patients  so  much  discouragement.  ^       „^ 

One  approaching  the  subject  in 
this  way  is  prepared  to  comprehend 
the  significance  of  the  destruction  of 
this  body,  and  to  appreciate  the  effect 
which  its  withdrawal  would  exert 
upon   the  relations  of  the  pelvic  vis-       An  p,astic  Rtr^  with  doci,lGcl  conves  curve 

below,  will  very  decidedly  yield  in  the  direc- 

cera.       Appreciating    the    important     tion  of  lower  arrow, 
relation  of  the  little  studied  and  little 

recognized  triangular  perineal  body,  he  recognizes  in  it  a  wedge  turned 
base  downwards  and  acting  as  the  keystone  of  an  arch  upon  the  integrity  of 
which  depends  the  support  of  organs  which,  deprived  of  its  co-ordinating 
mechanical  influence,  would  tend  to  fall  downwards,  bringing  with  them 
other  parts  which  they  in  turn  sustain.  Let  us  now  inquire  what  those 
influences  are  which  commonly  disable  this  wedge  or  keystone,  and  render 
it  inefficient  and  worthless.  The  perineal  body  may  lose  its  tonicity  and 
efficiency  from  the  following  causes  : — 

1st.   From  constitutional  feebleness. 

2d.   From  feebleness  the  result  of  prolonged  overdistention. 

3d.  From  subinvolution. 

4th.   From  senile  atrophy. 

5th.   From  laceration. 


161  THE    FEMALE    PERINEUM; 

In  a  very  few  cases,  in  girls  of  weak,  delicate  fibre,  the  perineal  body 
will,  without  other  assignable  cause,  be  found  to  be  totally  worthless  and 
entirely  incapable  of  performing  its  functions.  Such  cases  are  not  com- 
monly met  with,  but  they  do  unquestionably  exist,  and  every  practitioner 
of  large  experience  must  have  met  with  them.  In  such  cases,  the  virgin 
vagina  presents  to  the  finger  the  characteristics  of  that  which  has  given 
birth  to  children,  and  not  only  vaginal  walls  but  perineum  are  extraordi- 
narily relaxed. 

Either  in  the  virgin,  the  nulliparous  married  woman,  or  the  multipara, 
the  uterus,  from  increase  of  its  own  weight,  or  from  suddenly  applied  pres- 
sure from  above,  may  become  suddenly  or  gradually  completely  prolapsed. 
When  such  prolapse  occurs,  and  the  uterus  for  along  time  remains  between 
the  labia,  the  perineal  body,  by  overdistention,  loses  its  power,  and  after 
restoration  of  the  uterus  to  its  place  remains  entirely  enfeebled.  This 
condition  is  likewise  produced  by  inversion,  the  presence  of  a  large  fibrous 
polypus,  or  the  wearing  of  large,  globular  pessaries. 

As  utero-gestation  advances,  not  only  does  the  uterus  grow  with  the 
growth  of  the  foetus:  the  vagina,  uterine  ligaments,  mamma;,  and  peri- 
neum likewise  undergo  a  physiological  hypertrophy,  which  continues  till 
delivery.  After  this  has  taken  place,  that  retrograde  metamorphosis, 
styled  involution,  may  fail  in  any  or  all  of  these  parts,  which  then  remain 
large,  lax,  and  wanting  in  contractile  power.  This  failure  may  affect  the 
perineum,  in  consequence  of  a  laceration  more  or  less  profound,  and  the 
absorption  of  septic  material  subsequently.  Or  it  may  occur,  as  subinvo- 
lution of  other  parts  often  does,  without  assignable  cause.  I  am  not  aware 
that  this  condition  attracted  any  attention,  as  connected  with  the  peri- 
neum, until  I  called  attention  to  it  in  this  work  some  years  ago.  As  to 
its  existence  there  can  be  no  doubt,  and  it  certainly  produces  evil  results 
which  are  scarcely  less  striking  than  those  resulting  from  laceration.  The 
difficulty  of  accounting  for  complete  loss  of  power,  as  evidenced  by  extreme 
relaxation  of  the  perineum,  will  be  recognized  in  the  literature  of  this 
subject  by  an  attempt  to  explain  the  condition  by  supposing  that  in  such 
cases  the  perineal  body  has  been  sundered  from  above  without  any  lacera- 
tion having  been  inflicted  either  upon  its  mucous  or  cutaneous  surface. 
This  is  a  very  convenient  way  of  solving  the  problem,  but  until  proof  of 
this  theory  is  given,  its  validity  may  well  be  questioned. 

Subinvolution  often  affects  vagina  and  perineum  simultaneously,  and 
although  the  latter  appear  to  be  normal  in  size,  and  uninjured  by  the  par- 
turient process,  it  is  found  loose,  atonic,  and  feeble.  The  anterior  vaginal 
wall  and  bladder  sag  downwards  for  want  of  support,  and  the  posterior 
vaginal  wall  and  rectum  protrude  over  the  ineffectual  perineal  barrier. 
Instances  of  this  pathological  condition  are  very  common,  and  uterine 
displacement,  as  a  result  of  it,  will  be  frequently  seen. 

Cases  of  complete  uterine  prolapse  in  very  old  women,  in  whom  both 


ITS    ANATOMY,    PHYSIOLOGY,    AND    PATHOLOGY.  105 

uterus  and  vagina  have  long  undergone  senile  atrophy,  are  not  by  any 
means  rare.  Here  the  uterus  does  not  descend  primarily,  but  an  absorp- 
tion of  the  adipose  tissue,  which  is  stored  away  around  the  vagina,  and 
serves  as  a  support  for  it,  occurs  as  the  decadence  of  advancing  age  shows 
itself,  and  a  perineum  hitherto  strong  becomes  inefficient  and  inactive. 

Kupture  of  the  perineum  may  simply  be  described  as  a  splitting  of  the 
perineal  body.  Laceration  in  the  first  degree  splits  the  triangle,  one  side 
of  which  is  covered  by  the  vagina,  only  for  a  short  distance;  one  in  the 
second  degree  splits  it  to  its  centre ;  while  those  in  the  third  and  fourth 
divide  the  triangle  entirely  through,  and  at  once  remove  the  keystone  from 
its  place  in  the  arch. 

Destruction  of  the  power  and  function  of  the  perineal  body,  more  fre- 
quently than  anything  else,  induces  anterior  and  posterior  displacements 
of  the  uterus  and  prolapsus  in  its  three  degrees.  Removal  of  the  perineum 
does  not  take  away  support  from  the  uterus,  but  it  alters  the  shape  and 
removes  the  supports  of  the  vagina,  and  causes  it  to  drag  upon  and  displace 
the  uterus  as  a  direct  tractor. 

A  curious  phenomenon,  which  occurs  in  about  one  out  of  a  hundred 
cases  of  destruction  of  the  power  of  the  perineal  body,  while  in  itself  not 
important,  serves  to  show  how  markedly  the  relations  of  the  pelvic  organs 
are  in  this  way  impaired.  I  allude  to  entrance  of  air  into  the  vagina. 
While  the  pelvic  organs  are  in  normal  condition,  the  close  apposition  of 
the  vaginal  walls,  already  alluded  to,  entirely  excludes  the  spontaneous 
entrance  of  air,  and  at  once  expels  it  if  forced  in.  Let  the  perineal  body 
be  entirely  exhausted,  however,  and  certain  positions  assumed  by  the 
woman  draw  air  into  the  canal,  which  subsequently  escapes  with  a  dis- 
agreeably explosive  sound.  This  occurrence  has  been  described1  under 
the  names  of  garrulitas  vulvae  or  flatus  vaginalis,  and  deserves  some  atten- 
tion, in  view  of  the  fact  that  it  alarms  patients  who  are  at  a  loss  to  account 
for  it,  and  mortifies  them  by  its  happening  at  untoward  times. 

So  intimately  are  gynecology  and  obstetrics  connected,  in  reference  to 
this  subject,  that  a  few  words  upon  its  relations  to  the  latter  will  not  be 
inappropriate.  It  is  no  exaggeration  to  say  that  a  very  large  proportion 
of  female  diseases  take  their  origin  in  the  mismanagement  of  the  lying-in 
chamber.  If  this  be  so,  and  no  gynecologist  will  deny  it,  to  the  obstetrician 
the  importance  of  the  perineum  in  this  connection  cannot  be  exaggerated. 
Its  rupture  furnishes  one  of  the  most  fruitful  sources  for  the  absorption  of 
septic  elements,  and  I  do  not  hesitate  to  say  that  thousands  of  women 
sutler  throughout  their  lives  from  uterine  displacements,  engorgements, 
and  vesical  and  rectal  prolapse  in  consequence  of  injuries  inflicted  upon  it 
during  the  parturient  act.      To  an  imperfect  comprehension  of  the  anatomy 

1  See  an  essay  by  Lohlein  :  Zeitschrift  fur  Geburtshulfe  und  Gyn'akologie,  Bd. 
v..  lift.  1. 


166  THE    FEMALE    PERINEUM; 

and  functions  of  the  perineum  I  attribute,  in  great  degree,  the  impression 
entertained  by  many  practitioners  that,  in  spite  of  all  that  is  said,  its 
rupture,  so  long  as  it  does  not  involve  the  anal  sphincter,  is  a  matter  of 
little  moment.  This  dangerous  dogma1 — which,  in  my  mind,  renders  him 
who  entertains  it  an  unfit  person  to  be  intrusted  with  the  grave  responsi- 
bilities of  the  lying-in  chamber — is  always  based  upon  the  fact  that  such 
a  practitioner  lias  seen  many  perineums  ruptured  during  labor,  and  even 
without  interference  on  his  part  has,  to  use  the  common  phrase,  "heard 
nothing  of  them  afterwards."  But  such  a  loose  method  of  drawing  deduc- 
tions is  hazardous  as  well  as  unphilosophical.  How  do  they  who  draw 
them  know  how  many  cases  of  septicaemia  which  have  occurred  in  their 
practice  have  been  due  to  the  exposure  of  lymphatics  and  bloodvessels  to 
the  entrance  of  septic  poison,  or  how  many  cases  of  uterine  displacement, 
or  vesical  and  rectal  prolapse,  treated  by  themselves  or  others,  have  been 
the  remote  consequences  of  perineal  lacerations,  regarded  at  the  time  of 
their  occurrence  as  of  no  importance?  If  septic  poisoning  destroy  his  pa- 
tient, the  medical  attendant  perhaps  attributes  her  death  to  "  puerperal 
fever,"  that  hydra-headed  monster  of  the  lying-in  chamber,  which  he  is 
satisfied  that  neither  he  nor  any  other  practitioner  could  have  prevented. 
To  account  for  remote  troubles  occurring  years  afterwards  is  equally  sim- 
ple in  his  philosophy,  for  has  not  the  patient  lifted  heavy  weights,  or  fallen, 
or  does  not  the  displaced  and  congested  uterus  present  sufficient  signs  of 
"chronic  metritis"  to  offer  this  as  a  scapegoat? 

Let  us  suppose  that  the  perineum  has  been  torn  during  labor  down  to 
the  sphincter  ani  muscle.  In  this  accident  the  vagina  is  always  torn, 
though  the  grave  consequences  attending  that  accident  when  occurring  in 
the  upper  half  of  the  canal,  are  here  prevented  by  the  intervention  of  the 
triangle  of  dense  elastic  tissue  which  exists  between  the  vagina  and  the 
rectum.  An  immediate  consequence  is  the  exposure  of  an  extensive  raw 
surface  indisposed  to  heal  by  first  intention,  richly  supplied  with  blood 
and  lymph  vessels,  and  quite  near  to  chains  of  lymphatic  glands,  intra- 
pelvic  and  inguinal.  Over  this  surface  the  flow  of  an  ichorous,  fetid,  and 
semi-putrid  animal  fluid  must,  in  spite  of  the  greatest  precautions,  steadily 
pass  for  from  two  to  three  weeks;  a  fluid  consisting  of  decaying  and  flaking 
decidua,  disorganized  blood,  and  quantities  of  muco-pus.  The  wonder  is, 
not  that  septicaemia  occurs  so  often  under  these  circumstances,  but  that  so 
many  cases  escape  it,  where  everything  seems  so  perfectly  arranged  to 
favor  it.  Let  one  imagine  a  wound  an  inch  deep  and  an  inch  and  a  half 
long,  made  in  the  thigh  near  the  groin,  or  on  the  arm  near  the  axilla,  and 
bathed  every  hour  of  the  day  with  the  lochial  discharges  of  a  parturient 
woman!     Would  he  regard  the  occurrence  of  lymphangitis,  phlebitis,  and 

1  See  upon  this  subject  an  excellent  paper  in  vol.  iv.  of  the  Am.  Gynecological 
Society's  Traus.,  by  Dr.  J.  Taber  Johnson. 


ITS     ANATOMY,    PHYSIOLOGY.    AND    PATHOLOGY.  167 

erysipelas  as  being  unlikely  consequences?  And  yet  this  is  what  occurs 
to  every  lacerated  perineum;  the  wound  thus  treated  being  in  no  manner 
protected  against  the  evils  incident  to  such  exposure. 

If  cases  of  decided  laceration  of  the  perineum  were  closely  followed  up 
from  the  lying-in  room  to  the  end  of  life,  and  all  the  evils  which  imme- 
diately and  remotely  arise  from  this  accident  intelligently  noted,  the  list 
would  be  a  long  one;  all  not,  of  course,  showing  themselves  in  every  case, 
but  some  occurring  to  one  woman  and  some  to  another.  It  may  be  thus 
presented : — 

Septicaemia. 

Anterior  and  posterior  uterine  displacement. 
Prolapsus. 
Cystocele. 
liectocele. 
Chronic  cystitis. 
Chronic  rectitis. 

Uterine  engorgement  and  hyperplasia. 
Subinvolution  of  uterus  and  vagina. 
Destruction  of  power  of  uterine  ligaments. 
Development  of  a  tendency  to  abortion. 
Impairment  of  sexual  gratification  to  the  male. 
Neuralgia  affecting  the  site  of  rupture. 
Presented  thus,   this  array  may  appear  unnecessarily  formidable,  but 
there  is  not  one   pathological  condition   mentioned  which  practical  men 
will  feel  inclined  to  question  the  occurrence  of,  as  a  consequence  of  puer- 
peral laceration  of  the  perineal  body. 

As  for  me,  I  freely  confess  that,  at  the  moment  of  labor,  I  would  rather 
have  a  patient  sustain  a  fracture  of  the  radius  than  a  laceration  of  the 
perineum  down  to  the  sphincter  ani.  The  broken  bone  would  cause  pain, 
sleeplessness,  nervousness,  and  perhaps  fever;  but  it  would  not  expose  the 
patient  to  the  same  danger  of  septicaemia,  or  of  subsequent  uterine,  vaginal, 
rectal,  and  vesical  displacement. 

A  decided  laceration  having  occurred,  if  the  obstetrician  be  a  man  who 
has  familiarized  himself  with  the  anatomy  and  physiology  of  the  perineum, 
it  is  difficult  to  understand  how  he  can  doubt  the  propriety  of  early  closure 
of  the  wound,  both  as  immediately  preventive  of  septicaemia,  for  for  forty- 
eight  hours,  during  which  the  healing  process  seals  together  the  freshly-cut 
surfaces,  the  uterine  discharges  are  innocuous,  and  as  remotely  preventive 
of  all  the  evils  which  have  just  been  enumerated.  Should  the  operation 
prove  a  success,  the  gain  to  the  patient  will  be  great;  if  it  prove  a  failure, 
no  evil  will  have  been  done. 

That  there  are  sources  of  failure  for  immediate  operation  inherent  to 
the  condition  itself  cannot  be  denied  ;  but  equally  fruitful  sources  for  it  are 
to  be  found  in   ignorance  of  the  anatomy  of  the  part  to  be  repaired,  the 


168  PROLAPSE    OF    PELVIC    VISCERA. 

performance  of  the  operation  hurriedly  and  without  system,  and  the  fact 
that  the  obstetrician  has  cultivated  no  capacity  for  surgery. 

This  question  may  here  he  very  pertinently  asked  :  If  in  the  non-puer- 
peral state  the  perineum  should  he  severed  completely  down  to  the  sphinc- 
ter ani  muscle,  would  prolapse  of  vaginal,  rectal,  and  vesical  walls  neces- 
sarily occur?  No;  not  necessarily  ;  though  in  time  prohahly.  On  three 
occasions  I  have  done  this  for  the  delivery  from  the  vagina  of  very  large 
tumors,  and  to  test  the  question,  I  have  delayed  closure  of  the  perineum. 
In  no  case  did  prolapse  occun  And  why  did  it  not  do  so  when  it  so  com- 
monly ensues  upon  rupture  of  the  perineum  in  labor?  Because  laceration 
of  the  perineum  during  labor  or  abortion  is  very  commonly  the  cause  of 
subinvolution  of  vagina  and  perineal  body.  The  former  remains  a  large, 
lax,  uncontracting  bag;  the  latter,  a  yielding,  unresisting  mass  of  adipose 
tissue  and  skin. 

Even  after  labor,  prolapse  of  these  parts  does  not  always  ensue  upon 
rupture,  even  though  the  sphincter  ani  and  posterior  vaginal  wall,  for 
some  distance  up  the  rectum,  be  involved.  In  spite  of  the  accident,  in- 
volution goes  on,  the  strength  of  the  vaginal  walls  is  recovered,  and  they 
are  sustained,  although  their  shape  and  direction  are  altered,  and  they 
lack  the  support  of  the  perineal  body.  But  such  an  occurrence  as  this  is 
the  exception  and  not  the  rule,  and  in  spite  of  many  such  the  rule  stands 
unquestionable. 


CHAPTER  X. 

PROLAPSE  OF  VAGINA,  BLADDER,  RECTUM,  AND  INTESTINES. 

Prolapsus  of  the  Vagina. 

The  remarks  made  in  the  preceding  chapter  being  distinctly  borne  in 
mind,  it  will  be  easy  for  the  student  to  get  a  comprehensive  idea  of  pro- 
lapse of  the  pelvic  viscera  as  a  consequence  of  disability  on  the  part  of  the 
perineum,  and  the  subject  may  be  dealt  with  much  more  cursorily  than  it 
could  have  been  without  them. 

It  might  upon  very  valid  grounds  be  maintained  that  prolapse  of  the 
vagina,  or  rectum  and  bladder  are  so  intimately  connected  with  prolapsus 
uteri,  that  this  chapter  should  have  been  united  with  that  upon  the  latter 
condition.  I  have  especially  avoided  this  course,  for  the  reason  that  I 
wish  to  direct  the  reader's  attention  particularly  to  prolapse  of  the  vagina 
as  a  primary  condition,  one  often  long  existing  without  uterine  descent, 
and  very  frequently  preceding  that  state  as  a  causative  influence.  For 
any  repetition  which  may  occur  in  the  two  chapters,  I  offer  no  apology,  in 
view  of  the  great  importance  of  both  subjects. 


PROLAPSUS    OF    THE    VAGINA.  1C>9 

Definition  and  Synonyms The  mechanism  by  which  the  pelvicorgans 

of  the  female  are  kept  in  their  proper  positions,  and  relations  to  each 
other,  oilers,  in  its  simplicity  and  perfection,  an  excellent  example  of 
that  adaptation  of  means  to  an  end  which  is  so  often  repeated  in  the 
animal  economy.  The  uterus  is  so  sustained  that  when  necessity  requires 
it,  not  only  in  pregnancy  but  under  a  number  of  other  circumstances,  it 
may  rise  or  fall,  or  tilt  backwards  or  forwards,  while  the  rectum,  bladder, 
and  lowest  layer  of  small  intestines  are  kept  in  place  and  allowed  to  dis- 
tend and  empty  themselves  without  material  change  of  relation. 

When  the  tone  of  the  walls  of  the  vagina  is  impaired  and  they  pouch 
into  its  own  canal  so  as  to  fall  downwards  towards  the  vulva,  the  condi- 
tion is  called  prolapsus.  As,  however,  this  results  in  descent  of  the  uterus, 
small  intestines,  bladder,  and  anterior  wall  of  the  rectum,  it  is  often  in- 
cluded under  the  names  of  prolapsus  uteri,  cystocele,  enterocele,  or  recto- 
cele.  As  considerable  diversity  of  opinion  exists  concerning  the  nature 
of  prolapsus  vagina?,  it  is  necessary  for  us,  before  proceeding,  to  compre- 
hend its  definition  with  perfect  clearness.  By  some  it  is  maintained  that 
hernia  of  neighboring  viscera  into  the  vagina  should  not  be  included 
under  the  head  of  prolapsus,  which,  as  Colombat  declares,  is  an  "  inver- 
sion of  the  internal  lining  membrane,  caused  by  infiltration  of  the  cellular 
texture  that  unites  the  mucous  to  the  subjacent  membranes."  By  others 
it  is  believed  that  true  prolapse  is  impossible  without  simultaneous  dis- 
placement of  one  or  more  of  the  surrounding  pelvic  organs.  All  admit, 
of  course,  that  in  such  an  exuberant  development  or  hypertrophy  as  that 
which  occurs  during  pregnancy,  a  portion  of  the  canal  may  be  forced  out 
of  the  vulva,  but  this  is  not  what  is  ordinarily  meant  by  the  term  prolap- 
sus vaginae.  Dr.  Savage1  expresses  himself  thus  upon  the  point:  "Pro- 
lapse of  the  vagina  alone,  or  prolapse  of  the  vaginal  mucous  membrane 
alone,  are  two  affections  which,  anatomically  considered,  would  seem 
impossible." 

It  is  an  important  question  whether  there  can  be  prolapse  of  the  vagina 
without  rectocele,  cystocele,  or  uterine  prolapse.  The  anterior  or  upper 
wall  of  the  vagina  is  closely  bound  to  the  base  of  the  bladder  and  the 
front  of  the  cervix  uteri,  and  by  means  of  the  utero-sacral  ligaments  it  is 
indirectly  attached  to  the  sacrum.  This  wall  aids  in  support  of  the 
uterus,  bladder,  and  small  intestines.  The  posterior  wall  is  not  so  firmly 
bound  to  the  rectum,  though  the  adhesion  at  the  extremity  of  the  utero- 
rectal  pouch  of  peritoneum  is  quite  strong.  At  the  perineal  septum,  a 
point  a  short  distance  above  the  vulva,  and  just  at  the  upper  edge  of  the 
perineal  body,  the  muscular  walls  of  the  vagina  pass  off  to  attach  them- 
selves to  the  ischio-pubic  rami.  At  that  point  the  canal  is  constricted  by 
the  pubo-coccygeus,  the  true  sphincter  vagina?  muscle.     The  mucous  mem- 

1  Female  Pelvic  Organs. 


170  PROLAPSE    OF    PELVIC    VISCERA. 

brane  of  the  canal  passes  down  to  the  fourchette.  These  anatomical 
arrangements  account  for  the  fact  that  prolapse  of  the  vagina  without 
simultaneous  displacement  of  one  or  more  of  its  surrounding  viscera  is 
exceedingly  rare,  and  that  when  it  does  occur  as  a  distinct  disease  it  is 
very  generally  found  to  affect  only  the  posterior  wall.  I  have  met  with 
no  case  in  which  the  anterior  wall  has  decidedly  prolapsed  without  coinci- 
dent descent  of  the  bladder,  but  I  have  seen  repeated  instances  of  pro- 
lapse of  the  posterior  wall  without  alteration  of  the  position  of  the  rectum. 
Pathology. — Any  influence  which  impairs  the  natural  tonicity  and 
strength  of  the  vaginal  canal,  rendering  it  abnormally  voluminous  and 
lax  ;  which  alters  its  natural  shape  and  the  incurvation  of  its  walls ;  or 
which  destroys  its  lower  buttress  or  support,  will  tend  to  induce  this  affec- 
tion. As  pregnancy  and  parturition  combine  most,  and  often  all  of  these, 
they  very  generally  furnish  both  predisposing  and  exciting  causes.  The 
development  of  the  vagina,  and  increased  weight  of  the  uterus  dependent 
upon  the  former,  and  the  distention  of  the  canal  and  enfeebling  of  the 
sphincter  muscle  incident  to  the  latter,  all  unite  in  favoring  prolapsus. 
As  the  fibre  cells,  which  constitute  the  nascent  state  of  the  uterine  mus- 
cular fibres,  develop,  so  as  to  make  of  the  insignificant  non-pregnant 
uterus  the  powerful  organ  which  expels  the  child  at  full  term,  so  do  those 
of  the  vagina,  the  Fallopian  tubes,  and  the  uterine  ligaments.  By  the 
process  of  involution  which  diminishes  the  size  and  weight  of  the  uterus, 
these  parts  likewise  return  to  their  original  dimensions.  Those  influences 
which  arrest  this  important  process  in  the  uterus,  resulting  in  subinvolu- 
tion, likewise  affect  it  in  the  other  parts  mentioned,  and  render  them 
atonic  and  feeble. 

Prolapsus  vaginas  is  very  rare,  except  in  those  who  have  borne  children, 
although  it  may  occur.  Sir  Astley  Cooper  met  with  it  in  a  girl,  aged 
seventeen,  who  was  admitted  into  Guy's  Hospital,  for  supposed  prolapsus 
uteri,  and  Prof.  Meigs1  mentions  that  Dr.  Mutter,  of  Philadelphia,  saw  it 
occur  in  a  child  six  months  old  in  consequence  of  a  convulsion. 

Causes From    what  has  just    been    said    the    following   causes    will 

naturally  suggest   themselves  as   those  most    likely  to  produce   this  dis- 
placement : — 

Violent  efforts  of  the  abdominal  muscles  ; 

Repeated  parturition  ; 

Senile  atrophy  of  vaginal  walls  ; 

Rupture  of  perineum  ; 

Previous  distention  by  tumors; 

Long-continued  vaginitis; 

Subinvolution  of  the  vagina  and  perineum. 
Of  all  these  causes  the  last  is  the  most  frequent,  more  especially  when 

1  Meigs's  Translation  of  Colotubat. 


PROLAPSUS    OF    THE    VAGINA.  171 

it  accompanies,  as  it  often  docs,  partial  rupture  of  the  perineum.  Next 
in  frequency  stand  senile  atrophy  and  absorption  of  surrounding  adipose 
tissue. 

It  is  evident  that  till  act  either  by  debilitating  the  power  of  tbe  vaginal 
walls  by  mere  mechanical  distention,  by  specifically  robbing  them  of  their 
tonicity,  or  by  removing  the  buttress  against  which  the  canal  rests  at  the 
vulva. 

Varieties. — The  displacement  may  be  of  two  forms,  acute  and  chronic. 
The  power  of  the  canal  may  be  overcome  by  a  violent  effort,  a  fit  of  cough- 
ing, uterine  or  abdominal  contractions,  or  similar  acts,  which  with  great 
suddenness,  force  the  contents  of  the  abdomen  down  upon  the  pelvic  vis- 
cera. This  occurrence,  which  is  very  rare,  is  generally  accompanied  by 
sudden  descent  of  the  uterus,  or  occurs  soon  after  parturition.  The  ordi- 
narv  form  of  the  affection  is  that  in  which  by  the  slow  and  steady  action 
of  one  or  more  of  the  causes  enumerated,  the  resistance  of  the  vagina  is 
gradually  overcome,  and  little  by  little  a  fold  is  forced  downwards  towards 
and  through  the  vulva.  The  first  variety  is  the  result  of  a  few  minutes' 
efforts;  the  second,  that  of  months,  or  even  years  of  morbid  action.  Pro- 
lapse of  one  wall,  partial  prolapsus,  as  it  has  been  styled,  is  often  lost 
sight  of  in  view  of  the  hernia  of  the  bladder,  rectum,  or  small  intestines, 
which  accompanies  it.  Hence  cystocele,  rectocele,  and  enterocele  may  be 
regarded  as  complications  of  the  affection. 

Course,  Duration,  and  Treatment. — A  sudden  attack  of  prolapsus  being 
overcome  by  proper  means,  and  the  patient  kept  quiet,  may  disappear, 
and  not  return  ;  but  in  that  variety  which  occurs  gradually  there  is  no 
limit  to  the  duration  of  the  disease.  Generally,  the  physician  is  not 
called  until  it  has  existed  for  a  long  time  and  become  chronic.  The  most 
important  results  of  the  condition  are  prolapse  of  the  uterus,  bladder,  and 
rectum,  one  or  more  of  which  are  almost  sure  to  ensue. 

Prognosis — The  prognosis  as  to  cure  will  depend  upon  the  degree  and 
duration  of  the  malady.  It  is  always,  whatever  be  its  extent,  susceptible 
of  considerable  relief  by  surgical  means,  but  generally  proves  incurable  by 
those  of  medical  character. 

Symptoms — Should  displacement  of  the  vagina  exist  alone,  that  is, 
without  creating  hernia  of  surrounding  organs,  the  patient  will  complain 
of  a  sense  of  discomfort  in  the  vagina,  with  a  tendency  to  bearing  down, 
as  if  to  expel  some  foreign  body  ;  a  feeling  of  heat,  fulness,  and  throbbing 
of  the  vulva  ;  a  certain  amount  of  pelvic  uneasiness  in  walking  or  making 
any  muscular  effort,  and  a  tendency  to  become  fatigued,  if  the  condition 
be  one  of  aggravated  character.  Physical  exploration  will  reveal  the 
presence  of  a  tumor  between  the  labia,  which  touch  will  demonstrate  to 
contain  no  liquid,  and  yet  not  to  be  solid  in  its  nature.  Sometimes  the 
mucous  membrane  covering  it  is  excoriated,  ulcerated,  and  purple  in  color; 
at  other  times  it  will  be  smooth,  shining,  tough,  and  covered  by  pavement 


172  PROLAPSE    OF    PELVIC    VISCERA. 

epithelium.  A  simple  vaginal  prolapse  of  any  extent  is,  as  has  been  stated, 
quite  rare.  "When  it  does  occur  it  generally  affects  the  postinior  wall,  but 
prolapse,  accompanied  by  hernia,  is  more  commonly  found  to  affect  the 
anterior  wall,  cystocele  existing.  Should  the  case  be  complicated  by 
vesical  or  rectal  prolapse,  the  symptoms  just  enumerated  will  present 
themselves  with  the  addition  of  others  dependent  upon  disturbance  of  the 
functions  of  the  part  which  forms  the  hernia.  In  one  case  the  prominent 
symptoms  will  point  to  the  bladder;  in  another,  to  the  rectum;  and,  in 
very  rare  instances,  to  the  small  intestines. 

As  the  treatment  of  prolapsus  vagina?  is,  with  slight  modifications,  the 
same  for  uncomplicated  and  complicated  cases,  it  will  be  considered  after 
the  subject  of  vaginal  hernia?  has  been  discussed. 

Cystocele,  or  Prolapse  of  the  Bladder. 

Cystocele,  or  vesico-vaginal  hernia,  consists  of  descent  of  the  bladder 
towards  the  vulva,  so  as  to  impinge  upon  the  vaginal  canal.  "When  the 
anterior  wall  of  the  vagina,  which  is  closely  adherent  to  the  bladder,  the 
base  of  which  it  in  part  sustains,  ceases  to  afford  the  required  resistance, 
the  bladder,  partly  under  this  influence  and  partly  under  that  of  traction, 
descends  and  forms  a  small  pouch  in  the  vagina.  This  is  at  first  very 
small,  but  gradually  it  increases,  until  at  last  it  forms  a  decided  tumor, 
which  protrudes  between  the  labia  majora.  The  pouch  thus  created  be- 
comes filled  with  urine,  which,  in  the  ordinary  act  of  micturition,  cannot 
be  evacuated,  from  its  being  contained  in  a  species  of  diverticulum.  This 
undergoes  decomposition,  free  ammonia  is  formed,  and  cystitis  or  vesical 
catarrh  is  established,  which  annoys  the  patient  by  pain,  heat,  vesical 
tenesmus,  and  scalding  in  urination.  Should  any  doubt  exist  as  to  the 
character  of  the  tumor  felt  in  the  vagina,  a  curved  sound  or  catheter  may 
be  passed  into  it  through  the  urethra  for  the  settlement  of  the  question. 

It  is  an  interesting  question  whether  cystocele  is  ever  the  cause  instead 
of  the  result  of  prolapse  of  the  vagina.  It  is  probable  that  it  may  be  so  in 
very  rare  cases,  though  such  a  connection  between  the  two  affections  must 
be  uncommon,  since  the  former  generally  occurs  in  women  who  have 
borne  children,  and  thus  been  exposed  to  influences  which  tend  to  diminish 
vaginal  resistance.  Scanzoni1  is  convinced  that  the  vesical  prolapse  is 
sometimes  primary,  and  due  to  irregular  spasmodic  contraction  of  the  fibres 
of  the  body  of  the  bladder  while  the  neck  remains  firm.  This  forces  the 
urine  to  the  fundus,  which  dilates  and  undergoes  displacement. 

Jiectocele,  or  Prolapse  of  the  Rectum. 
Rectocele,  or  recto-vaginal  hernia,  occurs  in  a  manner  similar  to  that 
by  which  the  bladder  descends.     The  posterior  wall  of  the  vagina  not  only 

1  Op.  cit.,  p.  497. 


ENTEROCELE,    OR    PROLAPSE    OF    THE    INTESTINES.         17:5 

ceasing  to  give  proper  support  to  the  anterior  wall  of  the  rectum,  but 
dragging  it  obliquely  downwards,  this  forms  a  pouch  which  soon  fills  with 
fecal  matters.  The  feces,  becoming  hard,  and,  in  consequence,  irritating, 
create  mucous  inflammation  and  discharge,  with  tenesmus,  obstinate  con- 
stipation, and  hemorrhoids.  The  tumor  thus  formed  will  sometimes  equal 
in  size  a  man's  fist,  and  protruding  over  the  perineum  give  some  difficulty 
in  diagnosis  from  its  size  and  solidity.  This  difficulty  will  at  once  disap- 
pear upon  rectal  exploration  and  the  use  of  an  enema  of  ox  gall  and  warm 
water.  In  one  instance  I  saw  a  patient  confined  to  bed  for  three  or  four 
months  from  one  of  these  sacculated  accumulations  of  feces,  under  the 
supposition  that  cellulitis  existed,  which  by  effused  lymph  had  completely 
blocked  up  the  pelvis.  It  may  be  supposed  that  such  an  error  will  rarely 
be  met  with,  yet  the  case  which  I  have  just  mentioned  occurred  to  a  prac- 
titioner of  great  experience  and  ability. 

Enterocele,  or  Prolapse  of  the  Intestines. 

Enterocele,  or  entero-vaginal  hernia,  consists  in  descent  of  a  portion 
of  the  small  intestines  into  the  pelvis,  so  as  to  encroach  upon  the  vaginal 
canal.  Such  a  descent  usually  occurs  in  this  manner  :  a  loop  of  intestine 
resting  in  Douglas's  cul-de-sac  stretches  this  serous  prolongation,  and, 
advancing  between  the  rectum  and  vagina,  pushes  the  posterior  wall  of 
the  latter  before  it  so  as  to  form  a  tumor  at  the  vulva.  In  a  similar  man- 
ner it  is  stated  that  the  intestine  may  advance  between  the  bladder  and 
uterus  and  depress  the  anterior  vaginal  wall,  but  this  must  be  rare,  as 
authors  of  extensive  experience  assert  that  they  have  never  met  with  it. 

Enterocele  is  not  an  accident  likely  to  produce  evil  results  unless  it 
occur  during  labor,  when  strangulation  may  take  place.  Even  at  this 
time  sucli  a  complication  is  very  rare,  for  the  free  passage  afforded  the 
displaced  intestine  back  to  the  abdomen  will  almost  always  preclude  this 
difficulty.  Dr.  Meigs1  relates  a  case  occurring  during  labor,  in  which  the 
progress  of  the  parturient  process  was  checked  by  a  large  mass  of  intestines 
until  he  succeeded  in  reducing  the  hernia.  He  says,  with  reason,  that  in 
such  a  case  strangulation  or  contusion  was  to  have  been  feared. 

One  very  momentous  aspect  in  which  these  hernias  must  be  viewed  is 
in  relation  to  puncture  of  vaginal  tumors,  occurring  during  labor,  for 
ascertaining  their  contents.  No  such  explorative  means  should  be  re- 
sorted to  without  careful  differentiation  of  vaginal  hernias  of  all  descrip- 
tions, and  especially  of  that  of  which  we  have  last  spoken.  The  peculiar 
sensation  to  the  touch,  of  a  tumor  filled  with  air,  a  resonant  sound  upon 
percussion,  the  detection  of  peristaltic  movements,  and  careful  exclusion 
of  all  other  forms  of  tumor  which  might  appear  under  the  circumstances, 
will  serve  to  avoid  error.      When  it  is  borne  in  mind  that  vaginal  tumors 

1  Notes  to  Colombat  on  Diseases  of  Women,  p.  211. 


174  PROLAPSE    OF    PELVIC    VISCERA. 

are  very  near  the  inflated  intestines,  and  that  they  often  yield  to  the 
touch  an  airy  sensation,  it  will  be  appreciated  that  great  caution  is  neces- 
sary in  arriving  at  a  diagnosis.  Even  when  the  investigator  feels  posi- 
tive in  his  diagnosis,  it  is  always  advisable  to  test  the  question  by  capil- 
lary puncture  and  aspiration.  Should  an  intestine  be  punctured  by  the 
little  needle  employed,  no  evil  will  result. 

The  following  case  illustrates  the  dangers  and  possibilities  of  erroneous 
diagnosis  in  these  cases  : — ' 

A  widow  set.  52,  mother  of  twelve  children,  the  last  born  twelve  years 
ago.  A  year  since  she  suffered  from  prolapsus  uteri,  which  was  replaced. 
Patient  presents,  on  examination,  a  swelling  about  three  inches  long,  red- 
dish-blue in  color,  protruding  between  the  labia  majora,  covered  with 
granulations  and  pus.  Diagnosis — Polypus  of  the  uterus  ;  operation  for 
removal.  After  suffering  severe  pain  in  the  abdominal  regions  for  several 
hours,  death  ensued.  Autopsy — In  the  pelvis  was  found  a  half  pound  of 
liquid  blood.  Uterus  and  ovaries  atrophied.  A  portion  of  the  great 
omentum  and  a  piece  of  the  transverse  colon  were  carried  away  with  the 
mass.  In  the  posterior  wall  of  the  vagina,  was  an  opening  about  5  cm. 
in  diameter.     24  cm.  of  omentum  and  10  cm.  of  the  colon  were  excised. 

Treatment  of  Vaginal  Prolapse  and  Hernia Should    the   accident 

have  occurred  suddenly,  reduction  should  at  once  be  accomplished,  and 
the  rcurrence  of  the  displacement  prevented  by  appropriate  means.  The 
bladder  and  rectum  being  evacuated,  the  patient  should  be  placed  in  the 
knee-chest  position,  and,  the  fingers  being  well  oiled,  steady  pressure 
should  be  exerted  in  coincidence  with  the  axis  of  the  inferior  strait,  until 
the  prolapsed  part  is  returned  to  its  place.  In  the  case  of  enterocele 
already  referred  to  as  treated  by  Prof.  Meigs,  the  patient  was  placed  upon 
the  left  side,  and  taxis  being  practised,  the  mass  suddenly  slipped  above 
the  superior  strait,  into  which  the  next  uterine  contraction  forced  the 
child's  head.  To  prevent  a  relapse  the  pelvis  should  be  elevated,  the 
patient  kept  perfectly  quiet,  tenesmus,  if  present,  relieved  by  the  use  of 
opium,  and  the  vagina  constricted  by  astringent  injections. 

But  sudden  cases  of  vaginal  prolapse  and  hernia  are  very  rarely  met 
with.  It  is  usually  those  which  have  slowly  and  gradually  established 
themselves  that  we  are  called  upon  to  treat,  and  these  are  always  obstinate 
ami  rebellious.  The  means  at  our  command  for  overcoming  such  cases 
are  the  following  : — 

1st.    Local  astringents  and  tonics; 

2d.   Development  of  retentive  power  of  the  abdomen; 

3d.  Supplementary  support ; 

4th.   Surgical  procedures. 
The  first  of  these  may  be  effectual  in  slight  cases,  but  in  those  of  graver 

1  Centralblatt  fur  Cbir.,  May  3,  1879,  p.  303  ;  Hosp.  Gazette. 


ENTEROCELE,    OR    PROLAPSE    OF    THE    INTESTINES.         175 

character  they  will  prove  insufficient.  The  tone  and  strength  of  the 
vagina  may  be  temporarily  restored  by  the  use  of  injections  of  large 
amounts  of  water  medicated  with  tannin,  alum,  or  zinc,  employed  night 
and  morning.  The  patient  should  be  sent  during  the  summer  to  a  water- 
ing-place, where  sea-bathing  and  injections  of  sea-water  into  the  vagina 
may  be  employed.  A  very  excellent  result  will  also  sometimes  follow  the 
use  of  vaginal  suppositories  containing  one  of  the  astringents  mentioned. 

Too  much  stress  cannot  be  laid  upon  the  influence  of  the  abdomen  in 
sustaining  the  pelvic  viscera.  An  impairment  of  its  force  by  want  of  ex- 
ercise, and  the  pernicious  habit  of  disabling  the  power,  and  impeding  the 
function  of  the  diaphragm  and  chest  muscles,  by  tight  lacing  and  the 
wearing  of  heavy  clothing,  is  one  great  cause  of  their  displacement.  Im- 
provement in  this  respect,  by  removal  of  the  depreciating  influences  men- 
tioned, and  recovery  of  lost  power  by  appropriate  exercises,  is  a  matter  of 
great  moment.  But  this  will  be  left  for  consideration  under  the  head  of 
Uterine  Displacements. 

Supplementary  Support — In  stout  women  an  abdominal  bandage  with 
perineal  pad,  by  relieving  pressure  from  above  may  accomplish  a  great 
deal  of  good  when  combined  with  complete  removal  of  all  constriction 
and  weight  of  clothing  about  the  waist.  In  thin  women  it  accomplishes 
nothing. 

The  vaginal  pessary,  an  instrument  of  decided  value  in  all  the  dis- 
placements of  the  uterus,  does  little  or  no  good  here.  In  many  cases  no 
pessary  which  rests  upon  the  walls  of  the  vagina  can  be  retained  within 
the  distended  canal ;  in  others  none  can  be  found  capable  of  resisting  the 
downward  pressure ;  while  in  all  increase  of  dilatation  and  atony  is 
effected  by  them.  It  is  true  that  for  a  time  apparent  good  results  from 
them,  but  the  hope  to  which  this  gives  rise  is  very  generally  delusive,  and 
very  soon  they  must  be  abandoned.  The  function  of  a  vaginal  pessary  is 
to  support  the  uterus  ;  not  to  sustain  the  vagina.  In  some  cases  an  ex- 
ception will  be  found  to  this  rule  in  Cutter's  cup  pessary  or  some  similar 
instrument  supported  by  an  external  attachment.  Here  sufficient  power 
is  afforded  for  support  of  the  uterus  at  a  high  point  in  the  pelvis,  which 
mechanically  puts  the  lax  vagina  on  the  stretch  and  prevents  its  prolapse 
together  with  that  of  the  bladder  and  rectum.  This  instrument  will  be 
shown  in  connection  with  prolapsus  uteri. 

Surgical  Procedures Of  these   there  are   three   which   may  prove 

effectual.  If  a  ruptured  perineum  seem  to  produce  the  want  of  support, 
the  operation  of  perineorrhaphy  may  be  all  that  will  be  necessary.  This 
is  described  in  the  next  chapter.  Should  this  not  be  sufficient,  colpor- 
rhaphy  should  be  performed  upon  the  anterior  or  posterior  vaginal  wall, 
as  one  or  the  other  seems  most  at  fault ;  and,  should  even  this  not  relieve 
the  condition,  the  remaining  wall  should  be  likewise  diminished  in  extent 
by  the  same  procedure. 


17(3  PROLAPSE  OF  PELVIC  VISCERA. 

Almost  all,  except  the  most  aggravated  cases,  which  are  accompanied 
hy  great  hypertrophy  in  the  vaginal  walls,  will  yield  to  these  three  pro- 
cedures, alone  or  combined. 

Colporrhaphy  or  Elytrorrhaphy} — The  idea  of  constricting  the  vagina 
so  as  to  diminish  its  calibre,  and  by  this  to  remove  the  traction  exerted 
by  its  fall  upon  rectum,  bladder,  and  uterus,  long  ago  suggested  itself  to 
the  minds  of  surgeons.  In  1823,  M.  Remain  Gerardin  made  the  sug- 
gestion before  the  Medical  Society  of  Metz,  but  the  operation  does  not 
appear  to  have  been  essayed,  for  the  writer  with  a  great  deal  of  patriotic 
zeal  states,  in  a  subsequent  essay  upon  the  subject,2  that  "  his  desire  had 
been  to  put  beyond  controversy  the  origin  of  the  operation,  and  to 
preserve  for  French  surgery  the  priority  of  its  conception,  if  not  of  its 
execution."  While  this  surgeon  was  felicitating  his  country  upon  the 
conception  of  an  idea,  Dieffenbach,  in  Germany,  and  Heming,  in 
England,  proved  its  practicability  by  absolute  performance.  Dieffen- 
bach probably  operated  as  early  as  1830,  as  a  report  of  his  having  done 
so  was  published  in  June,  1831.  In  November,  1831,  the  late  Dr. 
Marshall  Hall,  of  England,  published  a  case,  in  which  at  his  suggestion 
it  had  been  performed  by  Dr.  Heming,  the  translator  of  Boivin  and 
Duges  on  the  Diseases  of  the  Uterus,  with  complete  success.  Subse- 
quent to  this  period  it  was  performed,  with  various  modifications,  by 
Fricke,  Scanzoni,  Velpeau,  Roux,  Stolz,  and  others  ;  the  operation  always 
consisting  in  "the  removal  of  a  band  of  vaginal  mucous  membrane  and 
union  of  the  two  lips  of  the  wound  in  such  a  manner  as  to  diminish  the 
calibre  of  the  vagina.     ....     Dieffenbach  refers  to  a  great  number 

of  women  who  were  completely  cured  by  the  procedure 

Fricke  out  of  four  cases  cured  three."3  Judging  from  these  quotations, 
it  appears  that  the  operation  has  been  known  and  practised  for  a  long 
time  on  the  continent  of  Europe,  especially  in  Germany.  In  England  it 
had  not  been  resorted  to  up  to  the  year  18G5,  if  we  may  judge  from  the 
statement  of  Dr.  Sims*  that,  after  a  discussion  upon  an  essay  presented  by 
himself  to  the  London  Obstetrical  Society  in  that  year,  Mr.  Spencer 
Wells  called  his  attention  to  the  operation  of  Mr.  Heming,  already  referred 
to,  with  the  assertion  that  "at  least  one  case  had  been  successfully 
operated  upon." 

The  operation,  probably  for  reasons  which  I  shall  mention  hereafter, 
had  fallen  entirely  into  disuse  when  Dr.  Sims5  revived  it  in  I808,  with 
certain  modifications.  His  operation,  which  I  shall  soon  describe,  differs 
very  essentially  from   that  adopted  by  his   predecessors,  and  should  in 

1  KoXtto?  or  SWfw,  "the  vagina,"  and  p«<f>»,  "  suture." 

*  Gazette  Medicale,  1835,  p.  558. 

8  Wieland  and  Dubrisay,  op.  cit.,  p.  533. 

4  Uterine  Surgery,  Eng.  ed.,  p.  319. 

6  Uterine  Surgery,  Eng.  ed.,  p.  308. 


COLPORRHAPHY    OR    ELYTRORRII  A  P1I  Y  .  177 

justice  be  regarded  as  the  parent  of  the  numerous,  I  had  almost  said 
innumerable,  modifications  of  it  which  have  since  appeared. 

It  is  a  mischievous  error  to  describe  this  operation  as  one  performed 
for  prolapsus  uteri.  That  that  displacement  is  one  of  the  complications 
often  existing  as  a  consequence  of  prolapse  of  the  vagina  is  true,  but  the 
operation  is  often  necessary  when  vagina,  bladder,  and  rectum  alone  are 
seriously  involved.  The  traction  exerted  by  the  descent  of  these  viscera 
is  frequently  the  cause  of  uterine  displacements  of  various  kinds,  and  that 
being  removed  by  the  operation,  the  consequent  displacement  disappears. 
But  the  student  must  remember  that  colporrhaphy  is  the  legitimate  surgical 
resource  for  loss  of  power  and  displacement  of  the  vagina.  To  take  a 
different  view  is  to  obscure  the  subject,  and  to  substitute  a  purely  empirical 
for  a  scientific  and  rational  arrangement. 

This  error  is  based  upon  the  belief  that  the  vagina  is  a  uterine  support, 
and  that  its  prolapse  allows  of  descent  of  the  pelvic  viscera;  not  that  it 
drags  them  down  by  its  own  inherent  tractile  power.  Some  writers 
describe  two  operations  for  narrowing  the  vagina,  one  for  the  cure  of  pro- 
lapsus uteri,  and  another,  both  being  for  anterior  elytrorrhaphy,  for 
prolapsus  vesicas !  This  is  surely  a  useless  and  mistaken  technicality. 
Whatever  supports  vagina,  bladder,  or  rectum  takes  away  direct  traction 
from  the  uterus,  and  allows  other  influences,  the  retentive  power  of  the 
abdomen  chief  among  them,  to  keep  the  uterus  in  position.  Carl  Schrce- 
der1  strikes  the  true  key-note  of  this  subject  when  he  declares  that  "  the 
only  circumstances  under  which  we  may  expect  a  satisfactory  result  from 
this  operation  are  when  the  vaginal  prolapse  was  the  primary  one." 

Sims's  Operation  of  Colporrhaphy The  patient,  being  put  under  the 

influence  of  an  anaesthetic,  is  laid  upon  a  table,  upon  the  left  side  as  for 
an  ordinary  speculum  examination,  and  Sims's  largest  speculum  intro- 
duced. A  curved  sound,  with  forked  tenaculum  points,  is  fixed  in  the 
cervix  uteri  and  made  to  cause  a  fold  in  the  anterior  vaginal  wall,  as 
shown  in  Fig.  51. 

The  parts  being  steadied  by  this  instrument,  the  operator,  by  means  of 
two  tenacula,  folds  over  the  opposite  walls  of  the  vagina  so  as  to  decide 
where  union  is  to  be  effected.  Having  settled  this  point,  the  mucous 
membrane  is  hooked  up  by  a  tenaculum  several  lines  above  the  meatus 
and  cut  by  curved  scissors.  The  tenaculum  lifting  the  piece  thus  cut,  and 
when  necessary  being  again  attached  to  the  mucous  membrane,  the  incision 
is  carried  upwards  so  as  to  cut  out  a  strip  extending  to  one  side  of  the 
cervix.     Then  another  furrow  is  cut  in  the  same  manner  on  the  other  side. 

The  sound  being  removed,  and  the  cervix  pulled  down  by  a  small  ten- 
aculum, the  two  transverse  lines  of  denudation,  shown  in  Fig.  52,  nearly 
uniting  the  two  arms  of  the  V,  are  made. 

1  Dis.  of  Female  Sexual  Organs,  Am.  ed.,  p.  208. 
12 


178 


PROLAPSE  OF  PELVIC  VISCERA. 


Sutures  of  silk  are  then  inserted  after  the  plan  employed  in  vaginal  fis- 
tula?, and  hy  them  silver  sutures  are  drawn  into  position.  The  passage 
of  sutures  should  be  commenced  at  the  apex  of  the  triangle  and  continued 
upwards. 


Fig.  51. 


Sims's  operation  for  colporrhnphy.    (Sims.) 


The  after  treatment  consists  in  perfect  quietude  in  the  horizontal  pos- 
ture, frequent  removal  of  urine  by  a  catheter,  and  the  production  of  con- 
stipation by  the  use  of  opium.  The  lower  sutures  may  be  removed  in  ten 
days,  and  the  upper  in  a  fortnight.  The  patient  should  be  kept  in  the 
recumbent  posture  for  two  or  three  weeks,  and  cautioned  against  immod- 
erate muscular  effort  for  some  time  afterwards. 

Dr.  Emmet,  finding  that  the  pouch  left  posterior  to  the  uterine  neck  hy 
this  procedure  was  sometimes  entered  by  the  cervix,  improved  the  opera- 
tion by  extending  the  transverse  denudations  so  as  to  make  them  meet. 
He  has  since  the  introduction  of  this  procedure  still  further  simplified  it, 
in  the  following  manner.  At  the  commencement  he  catches  up  with  a 
tenaculum  a  patch  of  mucous  membrane  at  the  proper  distance  to  one  side 
of  the  cervix,  and  snips  this  out  with  scissors.     On  the  other  side  he  doed 


COLPOIIRHAPHY    OR    ELYTRORRH  A  I'll  Y  , 


179 


the  same  thing,  and  also  on  the  posterior  wall  of  the  cervix.  ITe  then 
passes  a  wire  suture  so  as  to  bring  all  these  denuded  points  together,  face 
to  face,  and  twists  the  wire  so  as  to  fix  them.     The  result  is  that  the 

Fig.  52. 


Sims's  operation.     Shape  of  denudation  and  position  of  nterns. 

Fig.  53.  Fig.  54. 


Emmet's  operation  :  first  step. 

folding  of  the  vagina  accomplished  by  the 
sound,  as  shown  in  Fig.  51,  occurs  without 
the  use  of  that  instrument.  Catching  up  a 
piece  of  mucous  membrane  on  the  vaginal 
fold  of  each  side  with  the  tenaculum,  he  now 


Emmet's  operation  :  second  step. 


180 


PROLAPSE    OF    PELVIC    VISCERA 


cuts  it  out  and  nt  once  passes  a  suture,  and  thus  he  proceeds,  step  by 
step,  avoiding  a  great  flow  of  blood,  and  opposing  the  abraded  surfaces 
immediately,  accurately,  and  without  danger  of  passing  the  sutures  so  that 
they  will  not  be  symmetrical. 

As  I  have  already  mentioned,  there  are  numerous  modifications  of  this 
operation,  but  I  shall  mention  only  two  more,  one  for  elytrorrhaphy  upon 
the  posterior  wall,  or  posterior  elytrorrhaphy;  the  other  for  the  anterior 
operation. 

The  peculiarly  shaped  triangle  of  Sims  is  by  no  means  necessary  for 
this  operation.  Any  figure  which  results  in  constriction  of  the  vaginal 
wall  will  remove  traction  from  the  uterus  and  keep  the  vagina  from  pro- 
lapsing. Thus  Hegar  turns  the  apex  of  the  triangle  up,  and  the  base 
down,  while  others  resort  to  variously  shaped  denudations.  One  of  the 
simplest  for  both  posterior  and  anterior  wall  is  an  ovoid  figure,  the  whole 
of  the  extent  of  which  is  denuded.  This  form  dates  back  as  far  as  Dief- 
fenbach.     It  is  shown  in  Fig.  55. 

Fig.  55. 


Oval  denudation,  with  sutures  passed. 


This  operation  is  easier  of  performance  than  the  two  preceding  ones, 
and  gives  a  stronger  and  more  perfect  union  of  tissues  which  is  less  likely 
to  yield  to  pressure.  When  it  is  performed  upon  the  anterior  wall  the 
patient  should  lie  as  in  Sim.s's  operation  just  described  ;  when  upon  the 
posterior  wall,  upon  the  back,  the  thighs  flexed  upon  the  abdomen,  and 
the  lateral  walls  of  the  vagina  retracted  by  right  angled  retractors  held  by 
assistants.  Simon's  operation  of  "  posterior  colporrhaphy"  is  only  a  modi- 
fication of  this. 

Very  generally  both  anterior  and  posterior  elytrorrhaphy  are  entirely 
imperfect  resources  unless  combined  with   perineorrhaphy,  and  the  latter 


COLPORRHAPIIY    OR    ELYTIIORRII A  Pll  Y  .  181 

is  often  very  advantageously  united  with  these  under  the  name  of  elytro- 
perineorrhaphy  or  colpo-perineorrhaphy. 

I  now  proceed  to  describe  an  operation  which  has  acquired  considerable 
reputation  in  France,  and  which  seems  to  have  a  future  before  it.  It  is 
that  of  M.  Leon  Le  Fort,  and  is  thus  described  by  him.1 

"  The  uterus  being  entirely  outside  of  the  vulva,  without  reducing  it,  I 
make  on  the  anterior  wall  of  the  vagina,  the  patient  lying  on  the  back, 
four  incisions,  cutting  out  a  portion  of  mucous  membrane  which  yields  me 
a  raw  surface  about  six  centimetres  long  by  two  wide  upon  the  part  nearest 
to  the  vulva.  Then,  lifting  towards  the  abdomen  the  prolapsed  uterus  so 
as  to  see  the  posterior  face  of  the  tumor,  I  make  on  this  part  a  raw  surface 
similar  to  that  on  the  anterior  wall.  That  being  done,  I  in  part  replace 
the  uterus  so  as  to  bring  the  extremities  of  the  two  raw  surfaces  in  con- 
tact where  they  are  nearest  the  uterus.  I  then  apply  on  the  transverse 
border  three  sutures,  reuniting  longitudinally  the  anterior  and  posterior 
walls  of  the  vagina  ;  I  then  proceed  to  the  reunion  of  the  lateral  borders  by 
passing  from  each  side  a  silver  thread,  traversing  the  border  of  the  ante- 
rior freshened  surface,  then  the  corresponding  border  of  the  posterior 
freshened  surface.  A  thread  being  placed  in  a  similar  manner  on  the 
opposite  side  and  at  the  same  level,  it  is  sufficient  to  tie  these  sutures  to 
increase  by  the  apposition  of  the  opposite  vaginal  walls  the  reduction  of 
the  uterus.  This  reduction  is  completed  gradually  as  the  sutures  are  put 
in  place,  and,  when  the  two  raw  surfaces  have  been  united  throughout 
their  extent,  the  reduction  is  complete.  The  threads  which  have  served 
as  sutures  for  the  transverse  border  nearest  the  uterus,  being  hidden  in 
the  depth  of  the  vagina,  are  difficult  of  access  when  after  several  days 
union  is  effected ;  therefore  it  is  wise  to  give  to  these  threads  sufficiently 
great  length  in  their  twisted  part,  in  order  to  seize  them  easily  when  they 
become  free  after  section  of  the  part  embraced  in  these  loops." 

That  the  operation  of  elytrorrhaphy  has  effected  excellent  results,  there 
can  be  no  doubt.  The  journals  of  the  day  contain  numerous  reports  of 
cases  successfully  operated  upon  by  slight  modifications  of  the  methods 
here  described.  Its  disadvantages  are,  that  it  is  a  very  tedious  process, 
difficult  of  performance  for  one  not  familiar  with  this  kind  of  surgery,  and 
liable  to  failure  even  if  carefully  and  thoroughly  accomplished.  Further 
than  this,  it  is  unquestionable  that  in  a  large  number  of  cases  expansion 
of  the  vagina  recurs  in  time  in  spite  of  it.  Scanzoni2  goes  so  far  as  to  say 
that  the  operation  always  fails.  After  employing  it  thirteen  times  he  says: 
"  From  the  results  obtained  in  our  own  cases,  we  can  by  no  means  pro- 
nounce favorably  on  these  operations."  Courty3  says,  in  speaking  of  the 
operation,   "  The   majority  of  surgeons  to-day  regard  as  useless  a  method 

1  Le  Blond,  Traite  Elementaire  de  Cliir.  Gyn.,  p.  496. 

2  Op.  cit.,p.  15'J.  3  Mai.  de  l'Uterus,  p.  748. 


182  RUPTURE    OF    THE    PERINEUM. 

of  treatment,  which  is  likewise  not  devoid  of  danger."  A  reviewer  of  the 
New  York  Medical  Journal1  says  :  "  We  have  now  under  our  charge,  a 
patient  operated  upon  nine  years  ago  by  Sirns's  method  ;  in  a  year  the 
cicatrices  -had  given  way,  and  the  procidentia  returned.  Three  years  ago, 
she  was  operated  on  twice  by  Emmet's  method;  in  little  more  than  a  year 
the  bands  gave  way,  and  her  condition  was  worse  than  before,  for  the 
vagina  was  so  deformed  by  the  cicatrices  that  it  became  impossible  to 
adjust  a  pessary."  I  shall  not,  however,  strive  to  accumulate  evidence  of 
this  kind ;  I  have  offered  this  merely  to  sustain  my  statement  that  there 
are  certain  disadvantages  attaching  to  the  procedure. 

In  spite  of  all  this  my  experience  with  the  operation,  combined,  be  it 
understood,  with  perineorrhaphy,  leads  me  to  place  a  very  high  estimate 
upon  its  merits,  and  to  regard  it  as  meeting  a  difficulty  in  many  cases 
for  which  no  other  resource  is  offered  either  by  medicine  or  surgery. 


CHAPTER   XI. 

SURGICAL  MEANS  ADAPTED  TO  RESTORATION  OP  THE  PERINEAL  BODY. 

The  pathological  conditions  treated  of  in  the  two  preceding  chapters 
are  so  directly  connected  with  loss  of  power  in  the  perineal  body  that  the 
surgical  procedure  adapted  to  the  restoration  of  that  part  very  naturally 
comes  next  under  consideration. 

I  beg  the  reader  to  observe  that  the  operative  procedure  about  to  be 
described  is  not  limited  to  the  cure  of  laceration  of  the  perineum.  It  is 
appropriate  to  the  restoration  of  the  perineal  body  which  has  lost  its 
power  and  function  from  any  cause — rupture,  subinvolution,  senile  atrophy, 
constitutional  debility,  or  prolonged  overdistention.  The  indication  is  to 
till  the  triangular  space  created  by  the  anterior  curve  of  the  posterior  wall 
of  the  vagina  and  the  posterior  curve  of  the  anterior  wall  of  the  rectum 
with  a  dense,  resisting  body,  which  will  fit  into  the  space,  support  the 
walls  just  mentioned,  and  act  as  the  keystone  of  an  arch  which  directly  or 
indirectly  sustains  the  bladder,  the  rectum,  the  uterus,  and  the  intestines 
above.  This  is  the  comprehensive  and  broad  view  which  should  be  taken 
of  the  operation,  and  upon  its  thorough  appreciation  and  acceptance  much 
will  depend  which  is  to  follow. 

All  that  is  said  as  to  the  importance  and  treatment  of  destruction  of  the 
perineum  in  this  chapter  is  based  u|>on  the  facts  stated  in  Chapter  IX. 

'  Vol.  viii.  p.  523. 


RUPTURE    OF    THE    PERINEUM. 


183 


Before  reading  this  the  student  is,  therefore,  urged  to  peruse  that.  "With- 
out that  this  would  he  superficial  and  imperfect;  hy  its  aid  it  will  hecome 
much  more  thorough  and  comprehensive.  In  spite  of  the  fulness  with 
which  the  subject  is  dealt  with  there,  I  deem  a  slight  recapitulation  of 
salient  points  advisable  here.  In  doing  this  I  offer  no  apology  for  repe- 
tition of  former  statements,  for  I  am  an  advocate  of  the  plan  of  a  popular 
teacher  of  the  French  language  who  instructs  by  "repetition  sans  cesse." 

Anatomy Proceeding  in  close  proximity  with  each  other  towards  the 

pelvic  outlet,  the  vagina  and  rectum  diverge  at  a  point  above  the  peri- 
neum; the  one  arching  forwards  in  coincidence  with  the  pelvic  curve,  the 
other  slightly  backwards  towards  the  coccyx.  In  this  way  an  irregular 
triangle  is  created,  of  which  the  base  is  the  skin  between  the  fourchette 
and  anus,  one  side  the  posterior  vaginal  wall,  and  the  other  the  anterior 
wall  of  the  rectum.  This  space  is  filled  by  a  body,  having  the  union  of 
muscular  tendons  as  its  base,  and  which  is  itself  composed  of  fibro-elastic 
tissue.  One  of  its  sides  resting  upon  the  rectum,  the  other  gives  strength, 
elasticity,  and  firmness  directly  to  the  posterior  wall  of  the  vagina;  while 
this  wall,  being  by  it  pressed  against  the  anterior  or  upper  vaginal  wall, 
sustains  it  and  the  bladder  which  lies  upon  it.     Figs.  56  and  57  will  show 

Fig.  56. 


Perineal  body  perfect;  both,  vaginal  walls  sustained. 

the  relations  of  the  perineal  body  and  the  effect  of  its  removal  upon  the 
vaginal  walls.  The  anterior  or  upper  wall,  after  its  removal  by  rupture, 
lacks  support  and  falls  downwards,  prolapse  of  this  wall  occurring,  with 


184 


RUPTURE    OF    THE    PERINEUM. 


cystocele.  The  normal  direction  of  the  posterior  wall  is  also  destroyed. 
Instead  of  its  arching  forwards,  with  a  gentle  curve,  towards  the  vulva, 
its  lower  portion  runs  like  the  letter  S,  to  the  anus.  The  result  of  this 
change  of  direction,  with  the  coincident  loss  of  support  from  the  strong, 
elastic  perineal  body,  is  to  create  a  sagging  forwards,  and  soon  prolapse 
of  this  wall  follows  that  of  the  anterior,  and  uterine  displacement  is  a 
consequence. 

It  may  with  some  justice  be  remarked  that  Fig.  57  represents  the  peri- 
neal body,  not  simply  exhausted  but  split  through,  as  can  only  be  done  by 
laceration.  It  is  true  that  in  other  conditions  of  loss  of  power  there  is  an 
appearance  of  a  perineum  left,  but  it  is  the  semblance  of  a  departed  power, 
and  the  diagram  must,  in  such  cases,  to  a  certain  extent,  be  regarded  as 
schematic,  referring  to  absence  of  function  rather  than  of  tissue. 


Fig.  57. 


Perineal  body  removed  by  rupture;  both  vaginal  walls  robbed  of  support. 

When  a  woman  with  a  normal  perineum  is  placed  upon  the  back,  and 
the  finger  of  the  examiner  is  passed  into  the  vagina,  as  it  passes  over  the 
perineal  body  it  will  be  firmly  pressed  against  the  upper  vaginal  wall. 
Upon  the  withdrawal  of  the  finger,  the  separated  walls  will  be  observed  to 
come  in  contact  at  once  by  the  rising  of  the  posterior  wall.  If  the  perineal 
body  have  lost  its  power,  no  such  upward  pressure  is  found  to  exist,  and 
the  vaginal  walls  an;  discovered  to  be  in  less  close  contact. 

After  operation  for  restoration  of  the  destroyed  perineum,  an  examina. 
tion  of  this  kind  should  be  made.     If  the  upward  pressure  of  the  perineal 


RUPTURE    OF    THE    PERINEUM, 


18f> 


body  is  found  to  be  sufficient  to  bring  the  posterior  in  contact  with  the 
anterior  vaginal  wall,  the  object  of  the  operation  has  been  attained.  W  it 
do  not  so,  both  walls  will  lack  support,  in  spite  of  the  fact  that  the  super- 
ficial perineum,  the  base  of  the  perineal  triangle,  has  been  united  and 
appears  perfect.  The  latter  result  will  deceive  the  patient,  and  may  de- 
ceive the  surgeon,  with  false  hopes.  The  former  will  alone  give  future 
immunity  from  the  dangers  of  vaginal  prolapse  and  its  consequences. 

Fir..  58. 


Perineum  improperly  repaired  ;  perineal  body  not  restored  to  place  ;  vaginal  walls  not  sustained. 

Those  influences  which  destroy  the  power  of  the  perineum  and  render 
it  incapable  of  its  important  functions  are  the  following  : — 

Constitutional  feebleness  ; 

Prolonged  overdistention  ; 

Senile  atrophy  ; 

Subinvolution  ; 

Laceration. 
All  these,  with  the  exception  of  the  last,  have  been   considered   with 
sufficient  fulness  in   Chapter  IX.  ;  laceration  requires   more  careful  study 
here. 

It  being  now  understood  that  the  repair  of  a  perineum  the  power  of 
which  has  been  destroyed  frojn  any  of  the  causes  mentioned  is  to  be  con- 
ducted upon  exactly  the  same  principles  as  those  which  apply  to  the  opera- 
tion for  laceration,  I  shall  use  this  accident  as  a  means  of  illustrating  it 
and  confine  my  remarks  to  it  during  the  rest  of  this  chapter. 


186  RUPTURE    OF    THE    PERINEUM. 

Varieties  of  Perineal  Laceration — All  cases  may  be  classed  under  two 
heads : — 

Complete  and  Partial  Rupture. 

These  include  the  following  degrees  of  destruction  : — 

Superficial  rupture  of  the  fourchette  and  perineum,  not  involving  the 
sphincters ;  • 

Rupture  to  the  sphincter  ani  ; 

Rupture  through  the  sphincter  ani ; 

Rupture  through  the  sphincter  ani  and  involving  the  recto-vaginal 
septum. 

Complete  rupture  presents  such  serious  discomforts  as  a  consequence, 
that  partial  rupture  is  by  many  viewed  as  a  trivial  circumstance.  So  it 
is  by  comparison,  but  so  likely  is  it  to  be  followed  by  prolapse  of  one  or 
both  vaginal  walls  that  it  should  never  be  undervalued.  As  soon  as  such 
prolapse  occurs,  uterine,  vesical,  and  rectal  troubles  become  almost  in- 
evitable. 

The  evils  resulting  from  partial  rupture  are  by  no  means  insignificant, 
but  they  are  more  remote  and  more  tolerable  than  those  which  follow  com- 
plete.    "When  the  sphincter  ani  is  torn  through,  and  still  more  markedly 
when  the  rectal  wall  is  ruptured,  incontinence  of  feces  and  rectal  gases 
occurs  to  such  an  extent  as  to  embitter  the  life  of  the  unfortunate  patient. 
The  consequences  of  rupture  of  the  perineum  may  thus  be  presented  : — 
Subinvolution  of  the  vagina; 
Prolapsus  vaginae  with  cystocele  or  rectocele  ; 
Prolapsus  uteri ; 

Incontinence  of  feces  and  intestinal  gases  ; 
Prolapsus  recti. 

The  first  three  of  these  may  result  from  both  varieties  of  rupture,  com- 
plete and  incomplete.  The  last  two  attend  only  the  former.  Even  when 
the  two  passages  are  laid  into  one,  it  is  sometimes  surprising  to  see  how 
little  the  patient  may  suffer ;  but  generally,  under  these  circumstances, 
her  condition  is  truly  deplorable.  Fecal  matters  and  gases  pass  without 
control,  and  the  uterus,  vagina,  bladder,  and  rectum  tend  so  strongly  to 
descend,  that  exercise,  muscular  efforts,  or  tenesmus  produce  weariness, 
pelvic  pain,  and  traction  upon  the  broad  ligaments.  In  some  instances, 
so  great  is  the  disturbance  of  function,  that  the  unfortunate  woman  finds 
herself  an  object  of  disgust  to  her  associates  and  even  of  loathing  to  her 
husband. 

Subinvolution  of  the  vagina  is  rarely  alluded  to  as  a  consequence  of 
rupture  of  the  perineum  ;  but  I  see  the  two  conditions  too  often  coexistent 
to  regard  it  as  a  mere  coincidence.  "  The  muscular  walls  of  the  vagina," 
savs  Savage,  "  are  not  separable  into  coats  or  layers.  Two-thirds  of  the 
thickness  of  the  vagina,  varying  from  2-3  lines  above  to  5-6  below,  is 
made  up  of  this  muscular  portion  ;  the  inner  third   consists  of  a  dense, 


NATURAL    1IIST0RY.  187 

cellular  lining  membrane,  inseparably  united  to  it."  Tbe  elastic,  con- 
tractile elements  of  this  canal  are  identical  in  structure  with  uterine 
fibre  ;  and  development  occurs  in  them  as  in  those  of  the  uterus  under 
the  stimulus  of  gestation.  A  retrograde  metamorphosis  likewise  affects 
them  subsequent  to  labor.  As  this  process  is  often  interfered  with  in  the 
uterus  by  rupture  of  the  cervix,  so  is  it  in  the  vagina  by  rupture  of  the 
perineum.  Let  any  one  appeal  to  his  own  experience  for  the  frequency 
of  subinvolution  of  the  vagina  as  a  concomitant  of  rupture  of  the  peri- 
neum. It  may  be  objected  that  the  latter  often  results  from  difficult  and 
particularly  from  instrumental  delivery,  which  may  produce  both  condi- 
tions. An  examination  into  the  histories  of  cases  will  refute  this  ;  the 
result  is  often  produced  when  the  labor  has  been  very  rapid  and  unaided. 
It  may  again  be  suggested  that  prolapse  of  the  vagina,  a  consequence  of 
the  rupture,  excites  excessive  growth  in  its  walls ;  but  the  two  things  co- 
exist where  perineal  rupture  has  not  resulted  in  vaginal  prolapse,  almost 
as  often  as  where  it  has  done  so. 

Causes — The  power  of  the  perineum  may  be  destroyed  by  a  number 
of  influences,  for  which  the  reader  is  referred  to  Chapter  IX.  of  this  work. 
For  laceration  of  the  perineum  there  is  but  one  cause — parturition. 

Minute  details  upon  this  subject,  and  upon  means  which  should  be 
adopted  for  prevention,  will  be  found  in  works  upon  obstetrics.  All  that 
it  is  necessary  to  state  here  is  that  parturition  is  the  great  exciting  cause 
of  the  accident,  and  that  it  is  almost  never  met  with  in  nulliparous  women, 
except  after  removal  of  large  tumors  per  vaginam,  and  then  it  is  usually 
of  little  moment. 

Prognosis In  an  incomplete  case  of  slight  character,  where  the  four- 

chette  and  only  a  small  portion  of  the  perineal  body  are  involved,  no  evil 
usually  results.  Laceration  of  this  character  and  to  this  extent  is  the 
rule  in  first  labors,  and  not  the  exception.  It  requires  no  interference,  and 
is  so  insignificant  in  consequence,  that  it  is  not  included  under  the  sub- 
divisions which  I  have  mentioned.  Even  the  first  and  second  degrees  of 
laceration  which  I  have  tabulated  are  often  productive  of  no  evil,  and  may, 
unless  careful  inspection  be  made,  pass  unrecognized  by  both  physician 
and  patient.     But  this  is  the  exception  and  not  the  rule. 

The  third  degree  is  always  an  accident  of  gravity  ;  while  the  fourth  re- 
presents the  most  serious  form  of  the  condition.  The  greater  the  injury 
the  less  likely  will  be  spontaneous  recovery,  and  the  more  probable  the 
complications  and  results  which  have  been  mentioned. 

Natural  History  of  Perineal  Laceration It  is  the  general  impres- 
sion, and  one  which  I  formerly  shared,  that  any  laceration  which  does 
not  entirely  sever  the  sphincter  ani  may  unite  by  first  intention  without 
surgical  treatment,  and  that  none  which  converts  the  two  passages  into 
one  will  do  so.  Even,  however,  wdien  the  rupture  has  been  complete,  it 
has  been  asserted  that  spontaneous  cure  has  taken  plaee.     For  example, 


188  RUPTURE  OF  THE  PERINEUM. 

Peii1  once  affirmed  that  he  had  seen  a  woman  thus  injured,  and  who  passed 
her  feces  involuntarily,  entirely  recover.  De  la  Motte  declares  that  thirty 
years  afterwards  he  met  and  examined  Peu's  patient  in  Normandy,  and 
found  that  no  recovery  had  occurred.  Observation  at  the  bedside  has  led 
me  to  question  whether  union  by  adhesion  of  the  lips  of  these  wounds  ever 
occurs  spontaneously.  Very  certain  am  I  that  in  my  own  experience  I 
have  never  seen  one  do  so.  Let  the  limbs  be  bound  together  ever  so 
closely,  the  inevitable  passage  of  lochial  material  between  the  cut  sur- 
faces prevents  union  by  first  intention.  Repair  is  effected  by  granulation, 
and  is  often  very  good,  but  it  is  never  perfect.  I  am  not  prepared  to  say 
that  the  statement  is  absolutely  and  universally  true,  but  I  believe  it  to  be 
so  as  a  general  rule,  that  a  lacerated  perineum  left  to  nature  for  repair  is 
never  afterwards  as  perfect  as  it  was  before  the  occurrence  of  the  injury 
or  as  it  usually  is  after  proper  repair  by  surgical  means. 

How  then  is  it,  it  may  be  asked,  that  so  many  women  who  suffer  from 
laceration  of  the  perineal  body  do  not  suffer  from  the  consequences  which 
have  been  mentioned  ?  First,  because,  if  the  laceration  does  not  interfere 
with  vaginal  involution,  it  often  does  no  harm,  or  at  least  not  for  many 
years,  when  its  connection  with  displacements  is  entirely  forgotten  ;  and 
second,  because  the  imperfect  repair  effected  by  granulation  is  commonly 
sufficient  to  answer  all  purposes. 

I  am  fully  aware  that  many  will  be  found  who  will  positively  affirm 
that  they  have  seen  even  lacerations  in  the  third  and  fourth  degrees 
entirely  repaired  by  first  intention.  "False  facts,"  says  Cullen,  "are  more 
dangerous  than  false  theories."  This  I  strongly  suspect,  though,  as  I  have 
stated,  I  cannot  assert,  to  be  one.  The  ostium  vagina;  just  after  delivery 
is,  in  its  overdistended  and  always  slightly  lacerated  condition,  with  folds 
of  redundant  vagina  pressing  down  upon  it,  a  most  deeeptive  part.  I  have 
myself  often  been  deceived  as  to  serious  laceration  just  after  delivery, 
and  I  have  frequently  seen  others  similarly  misled.  A  prolific  field  is 
thus  open  for  error  to  the  superficial  and  inexperienced  examiner,  who, 
having  mistaken  a  slight  laceration  for  one  of  aggravated  character,  and 
finding  that  repair  has  been  effected  by  nature,  asserts  in  future  that  he 
has  known  spontaneous  recovery  even  after  most  extensive  destruction  of 
the  perineum. 

Should  the  case  really  be  a  serious  one,  however,  and  the  practitioner 
one  who  believes  that  nature  will  in  all  probability  repair  the  accident  and 
restore  the  perineal  body  to  its  important  functions,  a  golden  opportunity 
will  be  lost,  and  the  patient  in  all  likelihood  remain  a  sufferer  in  consequence. 

Time  for  Operation Upon  this  point  authorities  differ  widely,  some 

urging  immediate  action,  some  advising  delay  until  the  effects  of  parturi- 
tion have  entirely  passed  away,  while  others  compromise  the  matter  by 

1  Velpuau,  Trait6  de  l'Art  ties  Accoucheinents,  vol.  ii.  p.  639. 


TIM*    FOR    OPERATION.  180 

giving  preference  to  the  plan  of  waiting  a  few  days  only.  To  the  fir^t 
class  belong  Baker  Brown,  Demarquay,  Scanzoni,  Simon,  and  others  of 
equal  weight.  Scanzoni  thus  clearly  points  out  the  advantage  of  early 
interference:  ''The  operation  should  be  performed  just  after  the  delivery, 
because  it  is  more  likely  that  the  bleeding  lips  of  the  wound  will  then 
unite,  and  because,  vivification  of  the  edges  not  being  necessary,  the  pro- 
cedure is  simpler  and  less  dangerous."  The  worst  cases  of  the  accident 
with  which  we  meet  generally  follow  instrumental  or  manual  delivery,  and 
when  the  discovery  of  its  occurrence  is  made  the  patient  will  usually  be  in 
a  profound  anaesthetic  sleep.  Every  operator  should  be  prepared,  under 
such  circumstances,  to  attempt  repair  of  the  injury,  for,  if  he  succeed,  the 
patient  will  be  saved  much  suffering,  while  failure  will  not  in  any  wise 
depreciate  her  condition.  For  this  reason  no  case  of  obstetrical  instru- 
ments should  be  considered  complete  which  has  not  in  it  needles  and 
sutures  for  performance  of  this  operation.  I  have  commonly  resorted  to 
immediate  operation,  and  the  result  of  my  experience  leads  me  always  to 
adopt  it,  unless  the  sphincter  ani  and  recto- vaginal  wall  be  so  profoundly 
implicated  in  the  laceration  as  to  make  the  operation  a  serious  and  lengthy 
one,  or  necessarily  to  insure  the  passage  of  lochial  discharge  between  the 
lips  of  the  wound.  Among  those  who  are  opposed  to  immediate  inter- 
ference are  lloux  and  Velpeau  ;  while  Nelaton,  Verneuil,  and  Maison- 
neuve  advise  delay  for  a  few  days,  when  all  hemorrhage  will  have  ceased 
and  the  edges  of  the  wound  be  covered  by  granulations.1  There  are 
three  circumstances  which  tend  to  defeat  the  success  of  immediate  opera- 
tion. First,  it  is  often  performed  by  one  not  habituated  to  its  peformance ; 
and,  being  practised  upon  a  woman  who,  having  just  been  delivered,  is 
exposed  to  the  danger  of  post-partum  hemorrhage,  and  surrounded  by 
anxious  friends,  it  is  likely  to  be  finished  too  hastily.  Second,  the  lochial 
discharge,  constantly  passing  over  the  lips  of  the  wound,  is  very  likely  to 
enter  and  prevent  union.  Third,  the  operator  having  been  taught  to 
regard  the  perineum  as  the  superficial  layer  of  tissues  intervening  between 
the  fourchette  and  anus,  closes  this  by  correspondingly  superficial  sutures, 
leaves  the  upper  portion  of  the  perineal  body  open,  creates  a  pouch  for  the 
accumulation  of  putrefying  materials,  and  leaves  the  anterior  vaginal  wall 
and  bladder  without  support  in  the  future. 

My  advice  and  practice  with  regard  to  this  point  are  decidedly  to  give 
the  patient  the  benefit  of  the  doubt  and  to  close  the  rupture  at  once.  If 
failure  follow,  however,  never,  unless  there  be  some  special  reason  for  so 
doing,  attempt  another  operation  before  the  results  of  parturition  have 
entirely  passed  away.  This  will  not  be  before  the  lapse  of  two  months 
from  the  time  of  delivery ;  just  after  delivery  there  is  a  reason  for  operating 
which  has  passed  away  in  a  fortnight. 

/ 
1  Wieland  and  Dubrisay,  French  Trans,  of  Churchill  on  Dis.  of  Womeii. 


190  RUPTURE    OF    THE    PERINEUM. 

As  I  have  elsewhere  already  remarked,  it  is  my  conviction  that  a  very 
large  number  of  cases  of  uterine  disease  take  their  origin  in  the  lying-in 
chamber,  and  a  large  proportion  of  these  in  unrepaired  cases  of  lacerated 
perineum.  When  immediate  operation  becomes  the  rule  of  obstetric  prac- 
tice, the  numberof  cases  of  disease  thus  occurring  will  at  once  and  very 
decidedly  diminish. 

But  the  full  results  of  immediate  operation  will  never  be  exhibited 
until  the  obstetrician  studies  the  anatomy  of  this  part,  and  learns  how  to 
approximate  its  entire  divided  surface  by  sutures  carried  up  to  the  highest 
point  at  which  solution  of  continuity  has  occurred. 

Treatment  of  Cases  which  have  Cicatrized — The  operation  which  is 
now  generally  adopted  in  these  cases,  and  which  has  received  the  name 
of  perineorraphy,  consists  in  vivification  of  the  edges  of  the  lips  of  the 
wound  and  their  approximation  by  sutures.  Although  the  accident  for 
which  this  procedure  is  instituted  was  described  by  the  ancients,  no  sur- 
gical means  of  cure  were  ever  advised  for  it  until  the  time  of  Ambrose 
Pare.  He  advised  the  suture,  and  was  followed  in  its  use  by  his  pupil 
Guillemeau.  Subsequently  it  was  employed  by  Delamotte,  Saucerotte, 
Trainel,  Noel,  and  others.  Dieffenbach  employed  it  successfully,  adding  to 
the  operation  oblique  lateral  incisions  involving  the  skin  and  areolar  tissue, 
for  the  purpose  of  relieving  tension  upon  the  parts  brought  together  by  suture. 

About  the  year  1832,  Roux,  of  Paris,  obtained  the  most  brilliant  re- 
sults from  the  operation,  and  probably  its  elevation  to  the  position  of  a 
reliable  surgical  procedure  was  due  more  to  his  achievements  than  to  those 
of  any  other  individual.  He  employed  the  quilled  suture,  and  cured  by 
it  four  out  of  the  first  five  cases  operated  upon.  Although  such  success 
was  obtained  in  France  at  this  period,  we  find  English  writers,  as  late  as 
1852  and  1853, '  doubting  the  efficacy  of  sutures,  and  advising  that  assist- 
ance should  be  limited  to  aiding  the  efforts  of  nature.  Of  late  years  great 
advances  have  been  made  in  the  operation  by  Mr.  Brown  in  England  ; 
Verneuil,  Laugier,  Demarquay,  and  others  in  France  ;  Langenbeck  and 
Simon  in  Germany;  and  Sims,  Emmet,  Agnew,  and  others  in  the  United 
States. 

To  no  department  of  gynecology  does  there  attach  more  surgical  rubbish 
which  needs  a  thorough  clearing  away  than  to  perineorraphy.  It  has 
afforded  a  fruitful  field  for  attempts  at  originality  and  innovation  ;  succes- 
sive investigators  too  often  seeming  to  strive  not  so  much  for  simplicity 
as  tor  some  peculiarity  of  procedure  which  they  could  call  their  own. 
Stripped  of  this,  the  operation  is  a  simple  one,  and,  under  the  influence  of 
advancing  anatomical  knowledge,  has  reached  a  point  at  which  operators 
may  stand  in  unison.  Among  the  methods  which  I  think  should  at 
present  be  cast  aside  as  effete  material,  I  would  cite  the  use  of  the  quill 

1   Baker  Brown,  Surgical  Diseases  of  Women. 


INSTRUMENTS.  191 

suture,  cutting  the  tissue  alongside  of  the  perineum,  cutting  the  sphincter 
ani,  dissecting  flaps  from  the  neighboring  cutaneous  surfaces,  and  many 
others.  Let  the  operator  fully  understand  what  he  sets  out  to  accomplish, 
which  is  by  no  means  always  done  in  a  surgical  procedure,  and  he  will 
readily  appreciate  that  the  simplest,  easiest,  and  surest  method  of  doing 
this  is  the  best.  Let  him,  on  the  other  hand,  have  in  his  mind  a  dim, 
uncertain  knowledge  of  what  he  desires  to  accomplish,  and  let  him  fill 
his  mind  with  the  details  of  the  special  plan  of  this  or  that  operator,  and 
he  will  be  led  to  adopt  complicated  and  uncertain  procedures. 

In  description  1  shall  adhere  to  no  one  particular  and  exact  method, 
but  describe  that  combination  which  I  have  selected  as  best  in  my  own 
practice. 

Preparation  of  the  Patient — The  general  health  should  be  carefully 
investigated.  If  it  be  bad,  the  operation  should  be  delayed,  and  the 
patient  put  upon  tonics  and  placed  under  the  best  hygienic  circumstances. 
For  a  week  before  operation,  the  bowels  should  be  kept  lax  by  some  mild 
cathartic,  in  order  that  after  that  time  cure  shall  not  be  jeopardized  by 
the  coming  down  of  scybala:,  which  have  not  been  removed  by  a  cathartic 
given  twenty-four  hours  before  operation.  This  point  is  one  of  a  great 
deal  of  moment,  and  should  not  be  overlooked.  In  cases  of  complete  rup- 
ture it  is  better  even  to  give  a  fortnight  to  the  fulfilment  of  this  indication. 
A  compound  cathartic  or  compound  aloetic  or  rhubarb  pill  may  be  given 
every  twelve  hours,  or  a  saline  cathartic  at  the  same  intervals.  Free 
alvine  evacuation,  not  hypercatharsis,  is  what  is  required.  During  this 
time  the  vagina  should  every  night  and  morning  be  thoroughly  syringed 
out  with  warm  water  to  remove  secretions  and  quiet  local  irritation. 

Instruments  and  Appliances  needed These  will  consist  of  a  long  han- 
dled curved  scissors;  a  bistoury  with  narrow  blade;  a  tooth  forceps  and 

Fig.  59. 


S.7IEMAN,y  -  CO-NY 
Thomas's  tooth  forceps. 

Fig.  60. 


1TTO &  REYNDERi 


Slightly  curved  scissors. 


tenaculum;  one  dozen  small  sponges  (size  of  a  walnut),  fixed  in  handles 
ten  inches  long ;  artery  forceps ;  silk  ligatures ;  and  straight  darning  needles, 
threaded  with  silk,  which  is  double  and  tied  at  the  eye  of  the  needle  by  as 
small  a  knot  as  possible.     A  basin  of  water  should  be  in  readiness  to 


192 


RUPTURE    OF    THE    PERINEUM. 


receive  the  bloody  sponges,  and  a  pitcher,  bucket,  or  other  reservoir  at 
hand  to  supply  more  when  this  is  to  be  changed.  The  instruments  should 
be  kept  immersed  in  carbolized  water,  with  which  the  parts  should  be 
freely  bathed. 


Fig.  61. 


Emmet's  scissors  sharply  curved. 


Operation  for  Partial  Rupture. — It  is  a  matter  of  great  surprise  to  me 
that  no  distinct  separation  should  be  made  by  writers  between  the  descrip- 
tions of  operations  for  partial  and  complete  rupture.  The  first  is  a  proced- 
ure in  which  the  merest  tyro  should  succeed.  The  second  is  one  of  the 
most  delicate  and  uncertain  operations  in  gynecology,  in  which  even  the 
most  skilful  may  fail.  I  feel  sure  that  evil  has  arisen  from  confounding  a 
simple  and  difficult  procedure,  and  shall  make  a  wide  difference  between 
them. 

The  operation  for  partial  rupture  has  for  its  sole  object  the  restitution 
of  the  perineal  body.  That  for  complete  rupture  has  for  its  main  object 
the  restoration  of  the  power  and  functions  of  the  sphincter  ani.  After  the 
main  object  of  the  second  operation  has  been  attained,  that  of  the  first 
should  claim  attention. 

Before  describing  these  operations,  I  would  say  a  few  words  upon  divi- 
sion of  the  sphincter  ani.  I  have  operated  a  great  many  times  for  rupture 
of  the  perineum,  and  cannnot  recall  a  case  of  final  failure;  thus  far  I  have 
never   cut  the   sphincter.     My   experience,  confirmed  by  that  of  many 

others,  leads  me  to  indorse  Dr.  Savage's 
statement,  that  "the  success  of  operations 
for  the  closure  of  perineal  lacerations  is 
obviously  not  promoted  by  the  division  of 
the  superficial  anal  sphincter." 

Let  the  operator  keep  clearly  in  mind 
the  shape  and  dimensions  of  the  body  which 
he  is  about  to  restore.  It  is  a  triangle  with 
apex  above  and  base  below.  Two  sur- 
faces of  this  shape  are  to  be  vivified  and 
held  face  to  face  by  sutures.  That  is  the 
whole  operation. 

First  part  of  the.  Operation. — The  pa- 
tient, dressed  for  bed,  should  be  placed  upon  a  table  before  a  window  ad- 
mitting a  strong  light,  in  the  position  for  lithotomy,  and  put  under  the 


Fig.  G2. 


Profil''  view  of  perineum.  A  (',  rectal 
■wall.  A  B,  cutaneous  surface.  Ji  C, 
vaginal  wall.     (1'arvin.) 


OPERATION    FOR    PARTIAL    RUPTURE.  11)3 

influence  of  ether.  Four  assistants  will  be  serviceable,  although  three 
would  answer  the  purpose.  One  of  these  should  administer  the  anaesthetic, 
one  should  hold  each  knee,  and  a  fourth  should  attend  to  the  duty  of  handing 
the  required  instruments  to  the  operator,  and  washing  the  sponges  as  they 
become  bloody.  The  assistants,  lifting  the  feet  from  the  table  and  flexing 
the  thighs  so  that  the  edges  of  the  tibiai  will  be  horizontal,  should  hold 
the  knees  clasped  under  the  arms  and  steady  the  feet  with  the  hands  of 
the  same  side,  while  the  unoccupied  hands  of  the  other  side  retract  the 
labia  and  expose  the  ruptured  part.  These  directions  should  be  observed 
by  the  assistant  holding  the  right  knee;  he  who  holds  the  left  should 
do  so  with  the  right  arm,  clasping  it  with  this  and  retracting  the  labium 
with  the  right  hand,  while  with  the  left  he  sponges  the  wound  with 
sponges  held  in  long  handles,  which  do  not  cause  his  hand  to  obstruct 
the  operator's  view.  It  will  at  first  appear  that  it  would  be  difficult  for 
one  assistant  to  do  all  this.  Let  him  who  thinks  so  try  it,  and  he  will 
find  that  it  is  not  so,  and  that  such  arrangement  of  his  aids  will  be  greatly 
to  his  advantage.  This  operation,  like  so  many  others  in  surgery,  often 
fails,  or  at  least  drags  heavily  in  its  progress,  from  the  want  of  a  sufficient 
number  of  assistants,  to  each  of  whom  is  allotted  an  especial  duty. 

All  being  now  ready,  the  index  and  middle  fingers  of  the  two  assistants 
who  hold  the  knees  are  fixed  upon  the  labia  by  the  operator,  and,  the 
degree  of  traction  which  they  are  to  practise  being  regulated,  the  opera- 
tion is  begun. 

Seizing  the  tissue  just  above  the  anus  with  tooth  forceps  or  a  tenaculum, 
a  strip  of  mucous  membrane  is  removed  from  the  posterior  vaginal  wall 
and  from  the  original  site  of  the  perineal  body  upwards 
as  far  as  it  is  proposed  to  extend  to  the  rectal  side  of 
the  triangular  denunation  to  be  created  on  each  side.  /a\ 

Fig.  63  will  show  this  very  well.     The  furrow  just  al-       .       /  // 
hided  to  will  extend  from   D  to  B.     It  should  always       /f  f  / 
be  carried  to  the  point  where  the  normal  curve  of  the      I    ^"Cx 
posterior  vaginal  wall  is  altered  in  its  course,  by  loss  of      \ 
perineal   power,  and  begins  to  take  an  excessive  and         \ 
abnormal  curve,  the  whole  wall  being  now  shaped  like  \ 

S.     One  great  object  of  the  operation  is  to  change  the  V 

shape  of  this  wall  of  the  vagina  from  A  B  D  to  A  B  C.  I  \ 

Before  this   is   done,  pressure  upon   it  will  cause   the      **>/ 
lower  portion  of  the   S  to  sag  forwards.     After  it  h         6" 
done  the  whole  wall  under  pressure  from  above  down-       Schematic  view  of 

,         ...    .  ,    ,        ,,  -,    ,,  part  to  be  denuded. 

wards  will  be  supported  by  the  sacrum  and  the  tissues 

which   lie   upon  it  for  its  upper  curve,  and  by  the  perineal  body  for  its 

lower. 

The  rectal  side  of  the  new  perineal  triangle  then  is  created  by  denuda- 
tion of  the  posterior  vaginal  wall.     If  the  base  or  rectal  side  of  this  trian- 
13 


194 


RUPTURE    OF    THE    PERINEUM. 


Fro.  64. 


gle  does  not  involve  the  posterior  vaginal  wall,  what  does  it  involve? 
This  was  the  original  site  of  the  perineal  body.  Its  anterior  or  vaginal 
side  was  originally  vagina,  and  the  posterior  vaginal  wall  now  prolapses 

and  usurps  the  place  of  this  body. 
Baker  Brown's  operation  for  recto- 
cele1  consisted  of  a  colpo-perineor- 
rhaphy  based  upon  this  fact,  and 
every  one  who  has  closed  a  peri- 
neum since  his  time,  and  not  lim- 
ited himself  to  a  mere  episior- 
rhaphy,  has  performed  the  same. 
Mr.  Brown  was  very  soon  followed 
by  Savage,  who  gives  the  accompa- 
nying diagram. 

Savage  says  that  his  plan  "  in- 
cludes in  the  resection  all  the  re- 
dundant vagina  at  its  ano-vulvar 
margin,  in  the  first  place ;  and  in 
the  second,  the  removal  of  a  trian- 
gular portion  of  vaginal  mucous 
membrane,  the  middle  angle  ex- 
tending to  some  distance  upwards 
along  the  posterior  wall  of  the 
vagina,"  etc.  He  then  declares 
that  it  "causes  the  posterior  segment  of  vagina  to  approach  the  pubis  so 
as  to  offer  an  effectual  obstacle  to  the  prolapse."  This  method  of  operating 
was  the  natural  and  inevitable  outcome  of  an  effort  to  replace  the  perineal 
body,  and  every  operator  making  this  attempt  performed  more  or  less 
perfectly  colpo-perineorrhaphy. 

In  reference  to  the  origination  of  the  present  operation  of  perineorrhaphy, 
or  at  least  as  regards  all  its  essential  features,  it  may  be  stated  that  the 
credit  of  making  it  a  colpo-perineorrhaphy  and  rendering  it  a  remedy  for 
rectocele  belongs  to  Baker  Brown.  A  reference  to  his  work  will  put  this 
beyond  question,  as  he  represents  the  operation  in  a  diagram  with  this 
descriptive  statement,  "Operation  for  rectocele."  His  operation  combined 
all  that  is  essential  in  that  which  is  now,  with  little  modification,  generally 
accepted.  Since  his  publication  of  it,  no  one  has  materially  altered  it, 
except  Marion  Sims,  who  performed  the  important  function  of  stripping 
the  procedure  of  certain  superfluities,  like  section  of  the  sphincter  and 
the  use  of  quills,  which  were  not  merely  useless,  but  absolutely  hurtful. 

We  have  now  formed  what  is  to  be  the  base  and  line  of  union  of  two 
triangles,  which  meet  upon  the  furrow  just  created.     Now  catching  up  the 


Denudation  for  repair  of  perineum.     (Savage.) 


1  Surg.  Dis.  of  Women,  3d  Eng.  ed.,  p.  94. 


OPERATION    FOR    PARTIAL    RUPTURE, 


195 


Fig.  65. 


tissue  on  the  inner  side  of  one  labium  majus,  about  midway  between 
meatus  and  anus,  another  furrow  is  cut  extending  down  to  the  anal  origin 
of  the  first  furrow,  and  another  is  then  carried  from  the  point  selected  on 
the  labium  backwards  to  the  upper  or  vaginal  extremity  of  the  basic  fur- 
row. A  triangular  space,  covered  by  mucous 
membrane,  mapped  out  by  three  bleeding 
furrows,  will  be  left,  as  shown  in  Fig.  65. 

C  A,  furrow  extending  from  anus  up  the 
vagina  (the  rectal  side)  ;  C  B,  furrow  extend- 
ing from  anus  to  point  midway  up  labium 
majus  (cutaneous  side) ;  B  A,  furrow  extend- 
ing from  point  on  labium  to  vaginal  extremity 
of  rectal  furrow  (vaginal  side).  Now  the  tis- 
sue in  the  unabraded  triangle  D  is  removed  by 
tenaculum  and  scissors,  as  little  tissue  as  pos- 
sible being  cut  away,  and  a  bleeding  triangle 
is  left.  The  opposite  side  is  similarly  treated, 
and  the  result  is  two  such  triangles  placed 

base    to    base    Upon    the  line  C  A.       The  doll-       One  of  the  bleeding  triangles  wliich 
,  v  r-    ,i  i        ,i  t    ,i  are  to  be  created. 

bung  over  ot  these  upon  each  other,  and  the 

securing  them   in  contact  by  suture,  constitute  the  second   part  of  the 

operation,  as  shown  in  Fig.  GG. 


Fig.  Ci3. 


The  two  bleeding  triangles  about  to  bo  united. 


If  the  student  will  cut  two  triangles  shaped  like  Fig.  Go  out  of  thin 
board  and  unite  them  by  linen  pasted  upon  both  sides,  so  that  it  will  act 
as  a  hinge,  he  will  be  able  immediately  and  perfectly  to  comprehend  both 
the  first  and  second  steps  of  the  operation.  It  is  in  that  way  that  I  have 
best  succeeded  in  explaining  them  in  didactic  lectures. 


196  RUPTURE    OF    THE    PERINEUM. 

In  performing  the  first  part  of  the  operation,  I  very  commonly  begin  on 
one  side  and  cut  successive  strips  across  until  the  whole  surface  is  pared  ; 
but  the  method  which  I  have  mentioned  simplifies  the  procedure,  and  after 
adopting  it  once  for  the  complete  understanding  of  the  operation  the  ope- 
rator may  afterwards  do  otherwise. 

This  part  of  the  operation  may  be  performed  by  the  knife,  but  it  is  done 
more  expeditiously  and  with  less  hemorrhage  by  the  scissors,  as  Emmet 
has  so  justly  pointed  out.  Prof.  E.  W.  Jenks,  of  Chicago,  has  proposed 
another  method  of  denudation  which  wrll  be  found  described  in  an  inter- 
esting article  by  him  in  the  American  Journal  of  Obstetrics  and  Diseases 
of  Women  and  Children.1  This  consists  in  the  introduction  beneath  the 
mucous  membrane  of  a  pair  of  sharp-pointed  scissors  by  which,  without 
for  a  moment  removing  them,  he  by  rapid  snips  separates  the  membrane 
from  its  attachment  and  removes  it  with  great  rapidity  and  little  loss  of 
blood.     All  the  denudation  done  is  effected  in  this  manner. 

Dr.  Albert  Smith,  of  Philadelphia,  has  employed  in  these  cases  and 
recommends  the  use  of  a  large  dentist's  burr2  with  cutting  flanges,  which 
is  made  to  revolve  rapidly  by  a  treadle  which  dentists  now  so  commonly 
employ.  By  this  the  surface  is  rapidly,  thoroughly,  and  bloodlessly  de- 
nuded of  its  mucous  covering. 

The  whole  surface  having  been  pared,  the  operator  stops  and  carefully 
examines  to  see  if  any  arteries  are  spouting,  and  if  any  undenuded  sur- 
faces still  remain.  If  he  find  the  former  he  twists  them,  and,  if  necessary, 
ties  them  with  very  delicate  silk  ligatures,  which  he  cuts  short ;  if  the 
latter  he  catches  them  with  the  tenaculum,  and  with  the  bistoury  cuts 
them  away. 

The  first  step  of  the  operation  is  now  finished.  The  operator  should 
not  hasten  to  the  second,  for  the  tissues  should  be  exposed  for  a  while  that 
he  may  be  assured  against  hemorrhage.  Sutures  should  never  be  applied 
until  all  hemorrhage  has  been  checked. 

2d  part  of  the  Operation Now  taking  in  the  needle-holder  a  round, 

curved  or  straight  needle,  about  two  and  five-eighths  inches  long,  which 
will  cause  less  hemorrhage  than  the  needle  with  cutting  edges,  armed  with 
a  doubled  silk  thread,  giving  a  loop  about  eight  or  ten  inches  long  ;  he  in- 
serts it  opposite  the  lowest  external  angle  of  the  vivified  triangle,  which 
would  be  a  little  above  the  level  of  the  anus,  and  makes  it  pass  across  the 
middle  of  the  united  bases  of  the  triangles,  over  the  rectum,  and  emerge 
at  a  corresponding  point  on  the  opposite  side.  This  suture  is  nowhere 
visible  within  the   vagina,  for  it  lies  embedded  in  the  tissues   lying  over 

1  Am.  Journ.  Obstet.,  vol.  xii.  No.  11,  Ap.  1879. 

2  This  instrument  was  first  used  by  myself  in  the  operation  for  vesico-vaginal 
fistula,  but  shortly  afterwards  Dr.  Smith,  without  a  knowledge  of  the  fact,  em- 
ployed it  in  this  procedure. 


OPERATION    FOR    PARTIAL    RUPTURE. 


197 


Fig.  67. 


the  rectum.  It  may  be  passed  by  one  sweep,  or,  if  this  prove  difficult, 
may  be  drawn  out  at  the  middle  of  its  course,  and  reinserted.  This  suture 
is  twisted  at  its  extremities  and  left  in  position,  and,  another  being  taken, 
it  is  inserted  above  the  first,  and  made  to  pass  through  the  tissues  at  a 
higher  point  of  the  vivified  surface.  Guided  by  the  finger  in  the  rectum, 
it  is  kept  embedded  in  the  recto-vaginal  septum,  and  emerges  at  a  point 
on  the  other  side  corresponding  to  that  of  entrance. 

This,  like  its  predecessor,  I  am  in  the  habit  of  concealing  in  the  tissues, 
so  that  after  its  passage  it  is  nowhere  visible  within  the  vagina.  I  believe 
that  an  embedded  suture  excites  much  less  irritation  on  the  denuded 
surface,  and  acts  less  like  a  seton  upon  it  than  an  exposed  one.  In  this 
way  sutures  of  silk  are  passed,  and  by  them  those  of  silver  are  immediately 
drawn  into  place,  about  one-third  of  an  inch  apart,  and  inserted  at  a 
quarter  or  half. an  inch  from  the  edges  of  the  wound.  All  these  are 
concealed  from  view  except  the  last  one  or  two,  which  should  pass  under 
the  upper  angles  of  the  triangles,  and  catching  up  the  vaginal  tissue  at 
the  highest  point  of  the  de- 
nudation should  bring  them 
all  together. 

At  each  side  of  the  pe- 
rineal triangle  thus  form- 
ed, two  pockets  may  be 
created  in  which  putrid 
materials  may  collect.  To 
avoid  this  great  care  should 
be  taken  to  conceal  the  su- 
tures especially  at  these 
points.  Denudation  should 
likewise  be  most  carefully 
practised  there. 

For  the  details,  as  to  the 
method  of  drawing  the  wires 
into  place  and  twisting 
them,  the  reader  is  referred 
to  the  article  on  Vesico-va- 
ginal  Fistula.  After  the 
plan  there  described,  he 
twists  them  one  after  the  other  from  below  upwards.  If  it  appear  neces- 
sary, superficial  sutures  are  then  passed  between  the  deep  ones  to  approxi- 
mate the  cutaneous  surface  more  completely. 

At  the  risk  of  being  considered  prolix,  I  offer  still  another  diagram 
giving  a  profile  view  of  the  sutures  in  position,  and  pressing  one  triangle 
against  its  opposite.     The  sutures  will  be  seen  to  run  back  and  pass  through 


Shows  surface  denuded  uud  sutures  in  position. 


198 


RUPTURE    OF    THE    PERINEUM. 


the  posterior  vaginal  wall,  dragging  this  forward  as  a  background  or  base 
to  the  two  opposed  triangles  now  to  become  an  artificial  perineal  body. 

The  sutures  should  not  be  cut  short  but  left  about  two  inches  long,  then 
twisted  together  and  secured  by  a  small  piece  of  India-rubber  tubing, 
after  a  plan  suggested  by  Emmet  and  shown  in  Fig*  69.  The  patient  is 
then  put  to  bed ;  the  knees  are  bound  together ;  the  dorsal  or  lateral 
decubitus  preserved  ;  the  urine  drawn  by  catheter  every  six  hours ;  the 
vagina  kept  clean  by  syringing  with  tepid  water;  and  the  diet  made 
nutritious,  though  mild  and  unstimulating.  On  the  eighth  or  ninth  day, 
the  sutures  should  all  be  removed,  and  on  the  next,  the  bowels  should  be 
acted  on  by  a  saline  cathartic,  great  care  being  observed  to  prevent  tenesmus. 


Fig.  68. 


Fig.  69. 


Profile  view  of  recently  closed 
perineum,  sutures  in  place. 


Method  of  securing  the  ends  of  the 
sutures.     (Emmet.) 


Operation  for  Complete  Rupture — Complete  perineal  laceration  always 
involves  rupture  to  a  greater  or  less  extent  of  the  anterior  wall  of  the 
rectum.  If  rupture  of  the  bowel  extend  for  more  than  from  one  inch  to  an 
inch  and  a  half  above  the  upper  edge  of  the  sphincter  ani,  it  is  better  to 
close  it  by  a  primary  operation  consisting  of  vivifying  its  edges  and  unit- 
ing them  down  to  the  anus.  After  union  of  these  parts,  closure  of  the 
perineum  may  be  practised.  If  the  bowel  be  not  injured  above  an  inch 
and  a  half  from  the  sphincter,  one  operation  will  suffice  to  close  the  whole. 
I  would  not  be  understood  as  making  this  a  dogmatic  rule,  but  merely  one 
which  approximates  the  line  of  conduct  which  I  deem  best. 

The  sole  object  of  the  operation  for  partial  rupture  is  restoration  of  the 
perineal  body.  The  objects  of  the  operation  for  complete  rupture  are ; 
first,  restoration  of  the  sphincter  ani  muscle  to  all  its  power  and  functions; 
second,  closure  of  the  rectal  opening ;  and  third,  restoration  of  the  peri- 
neal body.     What  constitutes  the  main  object  in  the  first  operation,  is  the 


OPERATION  FOR  COMPLETE  RUPTURE, 


109 


least  important  of  those  striven  after  in  the  second.  The  operator  must 
then  appreciate  that  mere  closure  of  the  rent  in  the  genital  fissure  is  not 
what  is  desired.  He  may  gain  this,  and  not  benefit  his  patient  in  the  least, 
for  incontinence  of  feces  and  gases  may  continue.  Success  involves  always 
complete  union  of  the  ends  of  the  severed  muscle  and  complete  closure  of 
the  rent  in  the  bowel.  To  secure  these  the  ends  of  the  muscle,  spread 
out  and  expanded,  must  be  curled  up  and  approximated,  and  the  recto- 
vaginal septum  must  be  drawn  up  and  united  to  them.  With  these  facts 
in  view,  clearly  defined  and  appreciated,  the  difficulties  of  the  operation 
greatly  diminish.  To  no  one  are  we  so  much  indebted  for  their  demon- 
stration and  illustration  by  practical  results,  as  to  Dr.  Emmet,  of  this  city, 
who,  in  1873,  wrote  a  valuable  paper  upon  the  subject,  giving  a  clear 
exposition  of  the  peculiar  action  of  this  accident  upon  the  sphincter  ani 
and  of  the  best  method  of  restoring  it  to  its  normal  shape  and  functions. 

Let  Fig.  70  represent  the  perfect  sphincter,  Fig.  71  will  show  it  rup- 
tured and  spread  out,  with  the  point  of  insertion  and  exit  of  the  needles. 


Fig.  70. 


Fig.  73. 


The  dotted  line  shows  the  course  of  the  metallic  sutures  embedded  in 
the  tissue.  It  will  be  seen  that  the  remaining  recto-vaginal  wall  is  a  fixed 
point,  and  that  as  the  wire  is  twisted,  the  ends  of  the  muscle  are  elevated, 
and  the  three  points  approach  each  other  as  shown  at  c.  As  the  twisting 
goes  on,  these  points  come  nearer  and  nearer  together  as  seen  in  Fig.  72, 
until  at  last  they  unite  as  shown  in  Fig.  73. 


200 


RUPTURE    OF    THE    PERINEUM. 


Fig.  74. 


Should  the  first  needle  be  inserted  and  drawn  out  above  the  end  of  the 
broken  muscle,  as  shown  in  B  B,  Fig.  71,  the  tissue  at  this  point  will  be 
approximated,  and  the  ends  of  the  muscle  brought  close  together,  but 
absolute  and  complete  union  will  not  have  been  attained,  and  loss  of  func- 
tion will  still  exist.  The  first  suture  is  the  important  one,  and  must  catch 
the  ends  of  the  broken  and  expanded  muscle  so 
as  to  lift  them  upwards  into  contact  with  each 
other  and  with  the  recto-vaginal  septum. 

In  vivifying  the  parts  before  insertion  of  the 
needles  the  two  lateral  triangles  representing 
the  perineal  body  split  in  two  are  denuded,  and 
the  line  of  denudation  is  prolonged  backwards 
along  the  edge  of  the  recto-vaginal  septum. 
The  border  of  the  rectal  mucous  memhrane  at 
the  extremities  of  the  broken  muscle  as  far  as 
the  upper  end  of  the  rent  in  the  bowel  is  the 
guide  for  doing  this. 

Fig.  74  is  a  schematic  diagram  showing  the 
ruptured  bowel,  the  expanded  muscle  at  its 
anal  extremity,  the  insertion  and  exit  of  the 
needles,  and  the  course  (dotted  lines)  of  the 
embedded  sutures.  The  line  of  denudation  is 
marked  out  by  the  course  of  these  sutures. 

The  rectal  rent  presents  itself  to  the  operator 
as  an  imperfect,  isosceles  triangle,  apex  above 
and  base  below.  The  two  lateral  borders  of 
this  are  the  parts  to  be  vivified.  The  two  basic 
angles  are  on  a  lower  plane  than  that  of  the 
apex,  and  are  less  fixed  in  their  position.  As  the  three  angles  are  acted 
upon  by  the  constricting  influence  of  the  encircling  suture,  as  this  is 
gradually  twisted,  the  two  movable  basic  angles  are  elevated  to  the  plane 
of  that  of  the  apex  while  the  latter  is  by  traction  drawn  down  to  meet 
them.  Coincidently  the  denuded  sides  of  the  triangle  are,  of  course, 
approximated,  and  thus  the  rectal  opening  is  completely  closed. 

To  sum  up  this  part  of  the  subject,  the  rule  for  passing  the  first  suture 
consists  in  the  introduction  of  the  needle  as  low  down  as  the  lower  edge 
of  the  anus.  From  this  point  it  passes  upwards  through  the  recto-vaginal 
septum,  completely  encircles  the  rectal  rent,  and  comes  out  alongside  of  the 
lower  edge  of  the  anus  on  the  opposite  side. 

Let  the  reader  refer  to  Fig.  75  and  he  will  appreciate  that  a  suture  which 
takes  this  course,  like  the  string  at  the  mouth  of  a  bag,  puckers  the  open 
parts,  draws  them  into  apposition,  and  controls  the  action  of  the  sphincter. 
The  two  conditions  which  we  have  to  fear  as  sources  of  failure  after  this 


OPERATION  FOR  COMPLETE  RUPTURE. 


201 


Fig.  75. 


operation  are,  first,  recto- vaginal  fistula,  and    second    non-union    of   the 
sphincter.      This  method,  to  a  great  extent,  secures  us  against  both.     The 
subsequent  steps  of  this  operation  are 
the  same  as  those  of  that  for  partial 
rupture. 

I  have  in  a  large  experience  with 
this  operation  failed  four  times.  As 
it  is  from  our  past  failures  that  we 
must  learn  to  avoid  failure  in  the 
future,  I  shall  strive  to  give  the  reader 
the  benefit  of  my  experience.  In  two 
of  my  four  cases  perfect  union  was 
obtained,  but  the  rectum  was  found, 
in  spite  of  the  fact  that  in  both  pa- 
tients catharsis  had  been  kept  up  for 
a  week,  filled  witli  large,  hard,  scy- 
balous masses.  This  created  violent 
tenesmus,  and  destroyed  the  newly 
formed  perineum. 

In  the  third  case  a  large,  bulbous, 
rectal  plug  had  been  left  in  place, 
and  its  removal  ruptured  the  united 
extremities  of  the  muscles,  leaving 
the  perineum  whole. 

In  the  fourth  case  the  nurse  in  using  the  syringe  for  a  rectal  injection 
unquestionably  passed  its  nozzle  repeatedly  between  the  lowest  suture  and 
that  just  above  it,  leaving  a  central  opening  in  the  perineum,  which  consti- 
tuted a  recto-perineal  fistula,  the  sphincteric  union  remaining  perfect. 

Upon  the  experience  thus  obtained,  I  have  predicated  the  following  rules 
of  practice,  which  I  invariably  observe  and  strongly  recommend : — 

1st.  When  about  to  operate  for  complete  perineal  laceration,  give  two 
entire  iveeks  to  complete  evacuation  of  all  scybalous  masses  from  the  in- 
testinal canal.  This  tract,  it  must  be  remembered,  is  twenty-five  feet  long, 
and  keeps  fecal  masses  stored  up  in  it  for  months.  Do  not  practise  hyper- 
catharsis,  but  let  the  patient  have  two  medicinal  evacuations  in  every 
twenty-four  hours.  This  may  be  done  by  giving  one  compound  rhubarb 
or  compound  cathartic  pill  every  eight,  twelve,  or  twenty-four  hours,  ac- 
cording to  the  patient's  susceptibility  to  catharsis. 

2d.  During  this  time  feed  the  patient  freely  upon  animal  food  and  ani- 
mal broths,  wheat,  potatoes,  and  other  nutritious  articles  of  diet. 

3d.  During  the  first  four  days  after  operation  sustain  her  entirely, 
though  thoroughly,  upon  strong  animal  broths  alone,  avoiding  milk  espe- 
cially, which  creates  scybake  of  hardened  casein.  The  reliance  upon  milk 
for  avoidance  of  scybalse  is  a  mistake. 


Surface  denuded  in  complete  perineal  rup- 
ture, and  first  two  sutures  iu  position. 


202  RUPTURE    OF    THE    PERINEUM. 

4th.  Keep  the  bowels  constipated  for  four  days  after  operation — till  pri- 
mary union  takes  place.  At  the  end  of  that  time  they  should  be  acted 
upon  by  a  gentle  laxative  or  enema. 

5th.  If  a  rectal  tube  be  employed,  let  it  be  one  of  small  size. 

6th.  Should  an  enema  be  used,  let  the  physician  himself  administer  it, 
unless  the  capacity  of  the  nurse  be  above  suspicion. 

Every  surgeon  must  admit  that  no  detail  is  too  insignificant  for  his  per- 
sonal attention,  which  is  capable  of  turning  the  balance  in  favor  of  or 
against  the  success  of  an  operation  which  he  has  performed. 

I  have  already  stated  that  sometimes  the  rectal  rent  is  so  extensive  that 
it  cannot  be  closed  by  the  same  operation  as  that  by  which  the  perineum 
is  closed.  Under  these  circumstances,  which  I  have  encountered  several 
times,  colporrhaphy  should  be  first  performed,  and  immediately  or  at  a  later 
period  perineorrhaphy.  The  sutures  may  be  passed  by  a  suture  with  a 
needle  at  each  extremity  from  the  vagina  into  the  rectum,  and  be  left 
hanging  from  the  anus,  or  they  may  be  left  in  the  vagina. 

It  is  often  necessary  to  perform  two  operations,  one  posterior  colporrhaphy 
and  the  other  perineorrhaphy,  at  the  same  time,  for  fear  of  discouraging 
the  patient  by  too  frequent  resort  to  operation.  Under  these  circum- 
stances a  long  ovoid  denudation  should  be  extended  up  the  vagina  towards 
the  cervix,  and  the  edges  brought  together  by  catgut  or  silk-worm  gut 
suture,  and  then  perineorrhaphy  should  be  performed.  The  perineal 
sutures  being  removed  on  the  eighth  or  ninth  day,  the  animal  sutures  may 
be  left  in  the  vagina  to  undergo  absorption.  This  prevents  the  straining  of 
the  new  perineum  necessary  for  removal  of  silk  or  silver  sutures. 

For  this  purpose,  Jenks,1  after  denuding  a  tongue-shaped  extension  up 
the  posterior  vaginal  wall,  approximates  the  raw  surface  by  catgut  sutures, 
runs  down  upon  each  of  these  a  perforated  shot,  passes  down  upon  this  a 
piece  of  hard  rubber  tubing  two  and  a  half  inches  long,  and  puts  at  the  end 
of  this  another  shot  which  he  compresses  firmly.  Upon  removal  of  the 
compressed  shot,  the  tube,  uncompressed  shot,  and  suture  can  all  be  readily 
withdrawn.     Fig.  7G  shows  this  part  of  Jenks's  ingenious  operation. 

After  closure  of  the  perineum,  should  the  patient  tolerate  it,  a  rectal  tube 
may  be  introduced  occasionally  for  the  escape  of  air  from  the  bowel,  or  in 
place  of  this  a  large  catheter  may  be  kept  in  recto,  though  this  is  not  necessary. 

Great  danger  of  separation  of  the  lips  of  the  wound,  even  when  perfectly 
united,  occurs  on  the  occasion  of  the  first  alvine  evacuation,  when  scybalous 
masses  are  apt  to  pass  and  to  tear  the  newly  united  parts  asunder.  As  I 
have  stated,  I  have  twice  had  this  happen  in  my  experience  in  operations 
performed  in  private  practice.  To  prevent  this  unfortunate  occurrence, 
some  keep  the  bowels  acting  daily  from  the  time  of  operation.  Formerly 
I  kept  them  constipated  until  removal  of  the  sutures  ;  now,  in  consequence 

1  Loc.  cit. 


VAGINISMUS 


203 


of  the  accidents  to  which  I  have  alluded,  I  adopt  the  plan  which  Granville 
Bantock  endorses  in  an  excellent1  monograph  upon  this  operation,  that  of 
keeping  the  bowels  quiet  for  three  or  four  days,  and  then  acting  upon  them 
by  laxative  enemata. 


Fig.  76. 


Jenks's  operation  of  colpo-perineorrkaphy. 

A  variety  of  substances  are  now  used  as  sutures  in  this  operation.  The 
Germans,  following  the  lead  of  Simon,  still  cling  to  silk ;  in  England  and 
America,  Sims's  silver  wire  is  very  generally  used  ;  but  some  follow  the 
advice  of  Lister  in  employing  catgut,  while  Bantock  has  a  strong  bias  in 
favor  of  the  g;ut  of  the  silk-worm. 


CHAPTER   XII, 


VAGINISMUS. 

Definition This  affection  consists  in  a  peculiar  sensibility  or  hyper- 
esthesia in  the  nerves  of  the  vaginal  mucous  membrane  at  the  site  of  the 
hymen,  which  upon  irritation  are  supposed  to  produce  spasmodic  contrac- 
tion in  the  sphincter  vaginae  muscle. 

Frequency — Vaginismus  is  of  frequent  occurrence,  and  will  often  be 
met  with  in  practice.      It  has  received  little  notice  heretofore,  not  because 

1  On  Rupture  of  tlie  Female  Perineum.      London,  1878. 


204 


VAGINISMUS. 


of  its  rarity,  but  because  the  attention  of  practitioners  has  not  been  spe- 
cially directed  to  it.  Dr.  Sims  declares  that  during  twenty-four  months 
he  met  with  it  seventeen  times,  and  during  four  years  I  saw  thirteen  well- 
marked  cases. 

History The  fact  that  such  a  condition  occurs  and  becomes  a  morbid 

state  of  considerable  importance  was  known  to  Dupuytren,  Roux,  and 
Burns,1  of  Glasgow.  They  not  only  described  it,  but  adopted  an  operative 
procedure  which  has  since  been  revived,  and  is  even  now  by  many  re- 
garded as  the  most  reliable  method  of  cure.  Their  views  did  not  appa- 
rently attract  much  attention,  nor  was  their  import  really  appreciated 
until,  at  a  later  period,  they  were  insisted  upon  by  Professors  Simpson 
and  Scanzoni.  Between  August,  1861,  and  October  of  the  same  year,  it 
was  described  by  Debout,2  Michon,  and  Huguier,  and  just  afterwards  by 
Marion  Sims,  who  applied  to  it  the  appellation  which  I  have  adopted.  By 
these  authors,  incision,  subcutaneous  or  through  the  mucous  membrane, 
was  recommended,  in  imitation  of  earlier  investigators,  after  less  severe 
measures  have  failed  of  effecting  a  cure.  Since  the  time  last  referred  to, 
the  affection  has  been  allotted  a  space  in  the  various  systematic  text-books 
which  have  appeared  upon  gynecology. 

Anatomy  and  Pathology It  is,  I  think,  very  generally  accepted  as  a 

fact  that  the  bulbo-cavernosus  muscle  which  passes  over  the  clitoris  and 
forms  a  figure-of-8  with  the  sphincter  ani  is  the  constrictor  vaginae.  Dr. 
Savage  denies  this  positively,  declaring  that  "  the  constriction  of  the  vagi- 
nal ring  is  produced  by  the  pubo-coccygeus  muscle."  This  is  a  broad  and 
powerful  muscle  situated  within  the  pelvis  just  above  the  point  at  which 

the  vaginal  walls  branch  off  to 
seek  their  osseous  attachment. 
Arising  from  the  inner  surface  of 
the  pubic  bones  its  fibres  take 
various  courses ;  its  median  fibres 
descend  by  the  side  of  the  urethra 
and  vagina,  some  of  them  turnin"- 
in  between  the  vagina  and  rectum 
to  meet  similar  fibres  from  the 
opposite  side  in  the  perineal  body; 
another  more  outward  series,  turn- 
ing in  beneath  the  rectum,  inter- 
mix with  fibres  of  the  other  side; 
while  the  remaining  fibres  still 
more  outward  are  inserted  into 
the  sides  of  tl>e  coccyx.  Fig.  77 
shows  a  portion  of  this  muscle. 

Pubo-coccygeus  muscle.     (Savage.)  l 

'  Simpson,  Clin.  Lee.  Dis.  of  Women. 

*  Bui.  Gen.  de  Therap.  M6d.  et  Chir.,  1861. 


CAUSES.  205 

Certain  morbid  states  produce  so  great  a  degree  of  irritability  in  the 
nerves  supplying  the  vulva  and  lower  part  of  the  vagina,  that  upon  con- 
tact with  foreign  bodies  a  spasm  occurs  in  this  and  in  neighboring  mus- 
cles, which  constitutes  the  disease  that  now  engages  us.  The  attention  of 
some  has  been  chiefly  fixed  upon  the  nervous  condition,  the  pubic  nerve 
being,  according  to  them,  the  seat  of  the  difficulty,  while  others  have  espe- 
cially regarded  the  resulting  muscular  spasm.  It  is  curious  to  perceive 
how,  from  different  standpoints,  both  parties  were  led  to  the  same  surgical 
resource. 

Causes This  affection  bears  to  the  vagina  the  same  relation  which 

blepharospasm  does  to  the  eyelids,  or  laryngismus  to  the  larynx ;  and,  like 
those  affections,  is  not  ordinarily  a  primary  disorder,  but  one  which  results 
from  some  special  local  cause.  It  may  arise  from  excessive  nervous  irri- 
tability affecting  the  whole  system,  as  is  often  seen  in  hysterical  women, 
or  be  produced  by  some  local  disorder  of  apparently  insignificant  character. 
Prof.  Willard  Parker1  reports  a  case  which  was  due  to  an  irritable  carun- 
cle of  the  meatus  not  larger  than  a  flaxseed,  removal  of  which  resulted 
in  cure.  In  other  words,  it  may  be  an  idiopathic  affection,  or  symptomatic 
only  of  some  other  disorder. 

The  recognized  causes  of  the  disease  are — 

The  hysterical  diathesis; 

Excoriations  or  fissures  at  the  vulva; 

Irritable  caruncle  of  the  meatus ; 

Chronic  endometritis  or  vaginitis ; 

Pustular  or  vesicular  eruptions  on  the  vulva; 

Neuromata  ;2 

Fissure  of  the  anus;3 

Hypera3sthesia  of  the  remains  of  the  hymen ; 

An  abnormally  rigid  perineum  ; 

Disproportionately  large  size  of  male  organ. 
Professor  Scanzoni  in  August,  18G8,  published  his  views  upon  this 
subject.  During  the  preceding  three  years  he  had  seen  thirty-four  marked 
cases,  due  chiefly,  he  thought,  to  violent  efforts  at  sexual  intercourse, 
practised  upon  women  having  small  vaginas  and  well-developed  hymens. 
Scanzoni  found  that  twenty-five  of  his  thirty-four  patients  had  various 
functional  and  organic  difficulties,  which  in  twenty  cases  had  come  on 
after  marriage  ;  in  eleven,  there  was  congestive  dysmenorrhea ;  in  one, 
amenorrhea  had  existed  for  three  years;  in  thirteen,  there  was  chronic 
metritis  ;  four  had  either  ante-  or  retroversion  ;  in  one,  there  was  perime- 
tritis; in  seventeen,  chronic  uterine  catarrh  ;  in  fourteen,  vaginal  catarrh; 

i  Bui.  N.  Y.  Acad.  Med.,  vol.  i.  p.  439. 

2  Simpson,  Med.  Times  and  Gaz.,  1857,  vol.  i.  p.  336. 

3  H.  Dewees.     Baker  Brown. 


206  VAGINISMUS. 

in  one,  anteflexion;  in  two,  retroflexion  ;  nine  had  urinal  difficulties  ;  one 
had  inflammation  of  the  right  Bartholin's  gland ;  in  fourteen,  there  were 
symptoms  of  anaemia  ;  and  in  seventeen,  of  hysteria.  Although  the  sexual 
act  could  not  be  fully  completed,  conception  was  not  entirely  impossible, 
as  out  of  the  thirty-four  cases  two  had  conceived  ;  in  the  other  thirty-two, 
sterile  marriages  had  existed  from  one  to  eleven  years.  This  sterility  was 
not  due  to  want  of  sexual  desire,  but  arose  entirely  from  spasm  involving 
all  the  muscles  of  the  pelvis,  which  also  rendered  examination,  either  by 
the  touch  or  speculum,  impossible  without  the  use  of  an  anaesthetic.1 

Some  of  the  causes  which  I  have  enumerated  produce  vaginismus  by 
direct  irritation  of  the  nerves  of  the  vaginal  mucous  membrane;  others,  by 
creating  a  discharge  which  indirectly  establishes  the  same  condition. 

Dr.  William  Neftel,  of  this  city,  has  recently  published  some  very  inter- 
esting observations  upon  the  influence  of  lead  poisoning  in  creating  this 
neurosis.  He  records  four  very  striking  cases,  having  this  as  a  cause,  and 
in  one,  the  vaginismus  was  the  symptom  which  incited  an  examination  for 
poisoning  by  lead.     These  cases  were  successfully  treated  by  electricity. 

Symptoms  and  Physical  Signs The  patient  will  generally  complain 

of  excessive  pain  upon  sexual  intercourse,  the  mere  attempt  at  which  will 
throw  her  into  a  state  of  nervous  trepidation  and  apprehension.  This  and 
sterility  will  probably  be  all  that  will  have  attracted  her  attention,  though 
in  some  cases  a  marked  tendency  to  spasm  will  have  been  noticed  upon 
sudden  changes  of  position,  or  washing  the  genital  fissure.  One  or  more 
of  these  symptoms  call  for  a  physical  exploration,  when  the  following  facts 
will  be  recognized.  As  soon  as  the  finger  is  brought  into  contact  with  the 
site  of  the  hymen,  the  patient  will  probably  spring  from  her  place,  com- 
plain of  agonizing  pain,  and  evince  great  nervous  disturbance.  Should 
the  examination  be  persisted  in,  introduction  of  the  finger  will  be  found  to 
be  almost  impossible,  and  if  it  be  forced  into  the  canal,  a  violent  muscular 
contraction  will  be  perceived.  If,  instead  of  the  finger,  a  camel's  hair 
brush  or  a  feather  be  employed,  severe  pain  and  contraction  will  follow 
even  this  application  to  the  surface. 

Differentiation There  is  no  other  affection  with  which  this  can   be 

confounded.  All  that  it  will  be  necessary  to  decide  concerning  it  will 
be,  whether  it  is  an  idiopathic  or  a  symptomatic  disorder. 

Course  and  Duration In  its  duration  it  is  unlimited.  Cases  are  re- 
corded in  which  it  lasted  for  twenty-five  and  thirty  years,  and  unless 
relieved  by  art,  it  will  probably,  in  its  worst  forms,  become  a  permanent 
condition.  In  its  less  severe  type,  and  more  particularly  when  dependent 
uj>on  some  other  diseased  state,  it  may  often  be  relieved  by  mild  means, 
or  pass  away  without  treatment. 

Prognosis "  From  personal  experience,"  remarks  Dr.  Sims,  "  I  can 

1  New  York  Med.  Journal,  vol.  ix.  p.  181. 


TREATMENT. 


207 


confidently  assert  that  I  know  of  no  disease  capable  of  producing  so  much 
unhappiness  to  both  parties  to  the  marriage  contract,  and  I  am  happy  to 
state  that  I  know  of  no  serious  trouble  that  can  be  so  easily,  so  safely,  and 
so  certainly  cured." 

The  experience  of  Scanzoni,  Tilt,  and  others,  who  have  adopted  an 
entirely  different  treatment  from  that  pursued  by  the  last-mentioned  author, 
and  who  deprecate  the  use  of  the  knife,  leads  them  to  the  same  favorable 
conclusion.  In  my  own  experience  I  have  met  with  no  case  in  which  I 
have  not  been  able  to  give  relief,  either  by  operative  interference,  or  by 
the  complete  removal  of  the  disease  of  which  this  condition  was  a  symp- 
tom. 

Treatment Careful   search   should  be  made,   before   the  adoption   of 

treatment,  for  the  cause  of  the  affection.  Should  this  be  discovered,  hope 
may  be  entertained  that  its  removal  will  effect  a  cure.  Should  no  cause 
be  discovered,  or  its  treatment  not  be  followed  by  recovery,  the  general 
state  of  the  patient  should  be  altered  and  improved  by  exercise,  change  of 
air  and  scene,  vegetable  and  mineral  tonics,  sea  bathing,  and  cheerful 
society.  Riding  on  horseback  has  been  especially  advised,  but  rowing, 
bowling,  walking,  or  any  other  exercise  which  develops  the  system  and 
improves  the  tone  of  the  nervous  organism,  will  probably  answer  as  well. 
Local  treatment  calculated  to  soothe  the  excited  vaginal  nerves  should 
then  be  resorted  to.  The  free  use  of  vaginal  injections  containing  lauda- 
num, creasote,  or  acetate  of  lead  is  sometimes  productive  of  good.  Dr. 
Peaslee  thought  highly  of  an  ointment  composed  of  two  grains  of  atropine 
to  an  ounce  of  lard.  This  alkaloid,  or  the  extracts  of  opium,  belladonna, 
byoscyamus,  or  stramonium,  may  be  incorporated   in  an  ointment  or  in 

Fig.  78. 


Sims's  vaginal  dilator. 


suppositories,  and  applied  freely  to  the  sensitive  part.  In  some  cases  sup- 
positories containing  from  five  to  ten  grains  of  iodoform  prove  very  bene- 
ficial. At  the  same  time  the  glass  tube  represented  in  Fig.  78  should  be 
gently  inserted  into  the  vagina,  and  kept  there  for  as  many  hours  a  day  as 
practicable.  Its  presence  will  tend  to  benumb  the  nervous  sensibility, 
distend  the  vagina,  and  produce  a  tolerance  of  foreign  bodies.  During 
this  treatment  the  patient  should  live  apart  from  her  husband.  This  plan 
of  treatment,  simple  as  it  is,  combined  with   copious   vaginal  injections 


208  VAGINISMUS. 

used  night  and  morning  for  the  complete  removal  of  irritating  discharges, 
as  well  as  for  their  own  direct  sedative  effects,  will  often  prove  effectual 
and  avoid  the  necessity  for  a  surgical  procedure  of  some  gravity. 

That  the  operation  proposed  hy  Dr.  Sims  for  the  cure  of  this  condition 
is  effectual,  there  can  be  no  doubt.  I  have  myself  resorted  to  it  in  a  large 
number  of  very  aggravated  cases,  and  in  all  with  perfect  success.  But 
there  has  been  (or  some  time  in  the  minds  of  many  gynecologists  a  grow- 
ing distrust  of  the  necessity  of  a  resort  to  a  procedure,  which  is  reported 
in  one  case  to  have  resulted  in  fatal  hemorrhage.  In  many  cases,  even  of 
grave  character,  it  has  been  proved  that  by  distention  of  the  vagina,  either 
with  the  fingers  or  by  expanding  instruments,  and  subsequent  maintenance 
in  the  canal  of  a  vaginal  plug,  cure  can  be  accomplished  as  perfectly  and 
even  as  rapidly  as  by  the  cutting  method.  Two  eminent  authorities, 
Scanzoni  and  Tilt,  have  especially  advocated  this  plan  and  opposed  the 
operation  of  Sims.  Their  views,  as  reported  in  medical  journals,  I  here 
place  before  the  reader. 

"Of  more  than  100  cases  that  have  fallen  under  Scanzoni's  observation, 
in  times  past,  he  has  been  completely  successful  in  the  treatment  of  all  to 
which  he  was  able  to  give  his  personal  attention,  without  in  a  single  case 
having  recourse  to  the  knife.  The  first  condition  of  success  is  complete 
sexual  abstinence  ;  for  the  first  three  or  four  days,  a  tepid  sitz-bath  should 
be  used  night  and  morning ;  warm  local  bathing,  with  aq.  Goulardi,  or  the 
same  applied  with  lint,  several  times  a  day.  Defecation  must  be  regulated, 
and  friction  from  motion  carefully  avoided.  After  a  few  days,  the  sensi- 
bility of  the  parts  will  be  so  much  allayed  that  a  solution  of  arg.  nit.  x-xx 
grs.  to  3 j  of  water,  may  be  applied  with  a  brush.  After  about  eight  days' 
continuance  of  this  treatment,  vaginal  suppositories  of  ext.  belladonna  and 
cacao-butter  may  be  placed  behind  the  hymen,  and  in  contact  with  it,  daily. 
These  remedies,  either  alternately  or  simultaneously,  must  be  continued 
until  every  trace  of  inflammatian  has  disappeared,  and  the  normal  sensi- 
bility is  restored.  Generally  two  or  three  weeks  will  be  required  to  attain 
these  objects.  Then  dilatation  must  be  commenced  ;  but  for  this  purpose 
sponge-tents  are  useless.  A  graduated  series  of  glass  conical  specula  are 
best  adapted  to  this  object.  After  the  first  slightly  painful  attempt,  the 
patient  generally  will  be  able  to  introduce  it  with  facility,  and  it  may  be 
allowed  to  remain  from  one-half  to  one  hour.  Even  when  the  hymen  re- 
mains, it  will  not  be  necessary  to  incise  it,  as  dilatation  can  be  effected 
without  recourse  to  that  measure.  At  first,  the  dilator  may  be  used  every 
two  or  three  days,  then  every  day  or  twice  a  day  for  two  or  three  hours, 
gradually  increasing  the  size  of  the  dilator  until  the  object  shall  have  been 
attained,  which  in  some  instances  may  require  an  instrument  admitting 
dilatation,  as  that  of  Segalas.  Sitz-baths,  belladonna,  and  pencilling  with 
nitrate  of  silver  may  be  required  from  time  to  time,  and  the  cure  will 
usually  be  completed  in  from  six  to  eight  weeks.  It  will  be  seen  that,  al- 
though  the  treatment  of  Sims  is  attended  with  an  equally  satisfactory  result, 
it  is  of  a  much  more  serious  character  than  the  treatment  adopted  by  Scan- 


SIMS'S    OPERATION.  209 

zoni  ;  and,  after  the  operation,  the  success  of  the  treatment  depends  gene- 
rally upon  the  subsequent  dilatation.  The  time  required,  moreover,  is 
nearly  the  same  by  either  process."1 

Dr.  Tilt  takes  the  same  position  in  deprecating  resort  to  the  knife  and 
giving  preference  to  forcible  distention.  He  anaesthetizes  his  patient,  and 
introducing  both  thumbs,  back  to  back,  forcibly  distends  the  ostium 
vaginae  for  five  or  six  minutes.  He  then  keeps  a  large  vaginal  plug  in 
situ  by  a  T  bandage  for  a  number  of  days.  This  author  lays  especial 
stress  upon  the  necessity,  already  alluded  to,  of  first  removing  any  exist- 
ing uterine  or  vaginal  disease,  in  the  hope  of  simultaneously  curing  the 
secondary  trouble,  before  having  recourse  even  to  the  process  of  distention. 

Should  these  means  fail,  the  operation  of  removal  of  the  hymen  and 
section  of  the  perineal  body  may  be  practised.  It  will  be  observed  that  I 
do  not  say  of  the  sphincter  vaginae  muscle.  This  is  certainly  not  severed 
to  any  extent ;  and  it  is  highly  probable,  if  we  accept  Dr.  Savage's  anatomy 
of  it,  that  its  fibres  are  nowhere  involved  in  the  section.  My  impression 
is,  that  Sims's  operation  accomplishes  two  things  :  first,  ablation  of  the 
hymen  often  removes  nerves  which  are  in  a  condition  of  hyperaesthesia  ; 
second,  section  through  the  perineum  enlarges  the  ostium  vaginae,  and 
thus  removes  an  obstacle  to  intercourse. 

If  I  be  correct  in  this,  we  have  here  an  instance  of  the  injury  done  by 
theorizing  with  reference  to  a  subject  which  should  be  put  beyond  doubt 
by  anatomical  demonstration  on  the  cadaver.  No  one  would  have  done 
mischief,  if  told  to  enlarge  the  ostium  vaginae  by  section  ;  many  have 
caused  serious  hemorrhage  by  endeavoring  to  sever  the  bulbo-cavernosus 
muscle,  which  good  authorities  declare  to  be  no  sphincter  at  all. 

Sims's  Operation The  patient  having  been  anaesthetized,  and  placed 

on  the  back,  upon  a  table,  the  remains  of  the  hymen  are  entirely  excised 
by  a  pair  of  curved  scissors.  The  slight  hemorrhage  resulting  from  this 
will  soon  cease  under  the  application  of  a  compress  wet  with  ice-water,  or 
of  a  solution  of  the  persulphate  of  iron. 

The  index  and  middle  fingers  of  the  left  hand  are  then  passed  into  the 
vagina,  so  as  to  put  the  fourchette  on  the  stretch.  By  means  of  a  scalpel 
a  deep  incision  is  then  made  on  the  right  of  the  mesial  line,  terminating 
at  the  raphe  of  the  perineum.  A  similar  incision  is  then  made  on  the 
other  side,  the  two  being  united  at  the  raphe,  and  extended  to  the  perineal 
integument  and  through  its  upper  border.  Each  of  these  incisions  will 
extend  from  about  half  an  inch  above  the  upper  border  of  the  sphincter 
(meaning  evidently  the  bulbo-cavernosus),  to  the  perineal  raphe,  thus 
passing  across  the  muscle,  and  measuring  nearly  two  inches. 

After  this,  the  vaginal  dilator  is  placed  in  the  canal,  and  worn  for  two 
hours  in  the  morning,  and  three  or  four  in  the  evening,  according  to  the 

1  N.  Y.  Med.  Journal,  loc.  cit. 
14 


210  VAGINISMUS. 

tolerance  for  it  which  is  manifested.  Fig.  78  represents  the  glass  vaginal 
dilator,  which  is  three  inches  long,  slightly  conical,  open  at  one  end  and 
closed  at  the  other,  and  varying  in  size  from  an  inch  to  an  inch  and  a  half 
in  diameter.  This  instrument  iskept  in  place  by  a  T  bandage,  and  should 
be  worn  for  two  or  three  weeks. 

Burns's  operation,  more  recently  endorsed  and  practised  by  Sir  James 
Simpson,  rests,  it  appears  to  me,  upon  too  weak  a  basis  to  warrant  its 
use.  It  consists  in  section  of  the  pudic  nerve,  which  Sir  James  says 
"  may  be  exposed  by  cutting  through  the  skin  and  fascia,  at  the  side  of 
the  labium  and  perineum  ;  beginning  on  a  line  with  the  front  of  the 
vaginal  orifice,  and  carrying  the  incision  back  for  two  inches.  The  nerve, 
being  blended  with  cellular  substance,  is  not  easily  seen  in  such  an  opera- 
tion ;  but  it  may  be  divided  by  turning  the  blade  of  the  knife  and  cutting 
through  the  vagina  to  its  inner  coat,  but  not  injuring  that.  It  may  be 
more  easily  divided  by  cutting  from  the  vagina.  Slitting  merely  the  ori- 
fice of  the  vagina  will  not  do  ;  we  must  carry  the  incision  fully  half  an 
inch  up  from  the  orifice,  and  also  divide  the  mucous  membrane  freely  in 
a  lateral  direction."  Now  let  the  reader  examine  Savage's  plate,  show- 
ing the  pudic  nerve,  and  he  will  see,  that  to  sever  it  "  by  cutting  from 
the  vagina,"  the  incision  would  have  to  be  carried  as  far  as  the  ramus  of 
the  ischium  on  each  side,  where  it  lies  in  direct  contact  with  the  pudic 
artery. 

No  one  can  examine  a  diagram  showing  the  course  of  this  nerve  with- 
out strongly  suspecting,  that  its  section  is  an  operation  which  has  existed 
in  the  mind  of  the  operator,  and  never  really  been  performed  upon  the 
living  being. 

Upon  what  then  did  this  procedure  rest  for  its  good  effects  ?  Upon  the 
same  basis  as  that  for  the  supposed  section  of  the  sphincter  ;  severance  of 
the  tissues  at  the  ostium  vaginae  and  consequent  enlargement  of  the  en- 
trance to  the  vagina. 

The  practice  which  I  should  recommend  in  vaginismus,  with  the  light 
which  we  at  present  have  for  our  guidance,  is  the  following : — 

1st.  Remove  existing  uterine,  ovarian,  vaginal,  urethral,  or  rectal  dis- 
ease, if  any  can  be  discovered ;  insist  upon  the  patient's  living  absque 
marito;  let  her  use  copious  vaginal  injections  of  warm  water  twice  daily  ; 
use  the  local  anodynes  mentioned  by  rectal  or  vaginal  suppository,  or 
throw  into  the  vagina,  every  night,  by  means  of  a  syringe,  a  pint  of  fluid, 
in  which  are  dissolved  twenty  grains  of  chloral  ;  have  a  plug  inserted  into 
the  vagina  by  the  patient  and  retained  for  several  hours  every  day ;  give 
such  tonics  as  quinine,  strychnine,  and  iron  freely  ;  and,  if  it  can  be  ac- 
complished, let  the  patient  have  a  change  of  air  and  scene,  and  indulge  in 
sea  bathing. 

2d.  Should  this  plan  fail,  anaesthetize  the  patient,  and  by  means  of  the 
blades  of  a  trivalve   or  quadrivalve  speculum,  distend   the  ostium  vaginae 


VAGINITIS.  211 

thoroughly  ;  follow  this  by  the  use  of  the  vaginal  plug,  and  resort  to  the 
means  above  given  for  locally  soothing  and  generally  sustaining. 

3d.  Should  this  method  likewise  fail,  anaesthetize  the  patient;  remove 
the  hymen  by  scissors,  a  simple  procedure  ;  incise  the  perineal  body  ex- 
actly as  it  is  torn  in  parturition,  introduce  the  plug,  and  keep  it  in  sitti 
for  a  week,  removing  it  and  cleansing  it  daily.  After  this,  let  the 
patient  use  it  herself,  and  follow  out  the  directions  given  under  my  first 
caption. 

The  act  of  parturition  would  be  very  likely  to  remove  this  condition 
entirely,  but  unfortunately  one  of  the  most  constant  of  the  results  of 
vaginismus  is  sterility.  This  arises  from  the  fact  that  sexual  intercourse 
is  so  painful  that  it  is  imperfectly  performed,  or,  as  is  more  commonly  the 
case,  all  efforts  at  overcoming  the  obstacle  to  it  cease,  and  the  woman 
lives  a  single  life.  Should  this  state  of  things  be  found  to  exist,  the  patient 
may  be  thoroughly  anaesthetized,  in  the  hope  that  complete  connection, 
accomplished  under  these  circumstances,  may  result  in  pregnancy. 


CHAPTER   XIII. 

VAGINITIS. 

Definition  and  Synonyms The  mucous  membrane   lining  the  vagina 

is  subject  to  inflammatory  action,  which  receives  the  name  of  vaginitis. 
It  is  tlie  same  disease  which  by  certain  authors  has  been  described  under 
the  titles  of  blennorrhea  and  blennorrhagia. 

Anatomy   of  the    Vagina The   vagina    is    a   canal  formed  of  strong, 

muscular  elements  and  lined  by  mucous  membrane.  At  its  upper  ex- 
tremity it  is  attached  to  the  cervix  uteri,  with  which  it  unites  at  a  vari- 
able point,  but  usually  midway  between  the  os  internum  and  os  externum. 
This  canal  consists  of  three  coats  :  1st,  an  outer  coat,  formed  of  fibrous 
and  elastic  tissue  ;  2d,  a  middle  coat,  formed  of  unstriped  muscular  fibre 
and  fibre-cell,  which  are  subject  like  the  same  structures  in  the  uterus  to 
great  hypertrophy  during  utero-gestation  ;  and,  3d,  an  inner  coat  or  lining 
mucous  membrane,  composed  of  connective  tissue  and  elastic  fibre,  and 
covered  over  with  squamous  epithelium.  The  3d  extends  to  the  four- 
chette  ;  the  1st  and  2d  spread  out  at  the  upper  portion  of  the  perineum, 
making  the  perineal  septum,  and  attach  themselves  to  the  ischio-pubic 
rami.  Its  general  form  has  been  aptly  likened,  by  Dr.  Savage,1  to  that 
which  would  be  assumed  by  a  flexible  tube  if  shortened  to  nearly  half  its 

1  Op.  cit. 


212 


VAGINITIS, 


Filiform  papillae  of  the  vagina. 
(Kiliau.) 


Fig.  7S).  length  by  a  cord   passed  from  end   to   end 

through  one  of  its  sides.  The  ridge  thus 
formed  is  called  the  anterior  column  of  the 
vagina,  and  marks  the  vesico- vaginal  septum. 
It  is  about  two  inches  long,  while  the  poste- 
rior wall,  the  posterior  column,  as  it  is  called, 
is  twice  that  length.  The  anterior  column, 
or  cord,  which  shortens  the  vagina,  puckers 
its  investing  mucous  membrane  and  throws 
it  into  folds  or  rugas,  which  run  transversely 
towards  the  posterior  column.  This  mu- 
cous membrane  is  studded  with  papillae,  which  are  covered  by  pave- 
ment epithelium.  The  papilla?  of  the  vagina,  which  were  first  fully  de- 
scribed by  Dr.  Franz  Kilian,  were  regarded  by  him  as  having  for  their 
function  the  transmission  of  sensation.  He  represents  them  as  being 
thread-like  and  filiform,  as  shown  in  Fig.  79. 

Much  discussion  has  occurred  among  anatomists  as  to  the  presence  of 
muciparous  glands  between  the  folds  of  the  vaginal  mucous  membrane, 
some  asserting  and  others  as  positively  denying  their  existence.  The  re- 
searches of  Huschke,  Jarjavay,  Jamain,  Farre,  and  other  eminent  inves- 
tigators, enable  us  to  accept  their  existence  as  an  undoubted  fact,  though 
it  is  curious  that  Charles  Robin1  and  Sappey2  have  been  unable  to  discover 
them.  The  vagina  may  then  be  said  to  be  lined  by  a  mucous  membrane 
which  is  covered  by  epithelium,  and  thrown  into  folds  which  are  studded 
by  projecting,  filiform  papillae,  between  which  lie  numerous  muciparous 
follicles. 

Varieties  of  Vaginitis Vaginitis  assumes  three  forms,  which  differ 

from  each  other  sufficiently  to  require  separate   investigation.     They  are 
denominated  as  follows  : — 

Simple  vaginitis  ; 
Specific  vaginitis  ; 
Granular  vaginitis. 
Prof.  Ilildebrandt,  of  Germany,  has  recently  described  another  variety 
which  he  styles  "  adhesive"  for  the  reason   that  its  chief  characteristic  is 
to    produce   adhesions   between   the  vagina  and   uterus.     It  occupies  the 
upper  third  of  the  vagina  :  the  mucous  membrane  bleeds  readily;  and  the 
discharge  is  thick,  creamy,  and  sanguinolent. 


Simple   Vaginitis. 

Definition — This  variety  of  vaginitis  consists  in  inflammation  of  the 
mucous  membrane  of  the  vaginal  canal  from  some  cause  other  than  gonor- 
rhoea! contagion. 


1  Nysteu's  Dictionary. 


2  Descriptive  Anatomy. 


SIMPLE    VAGINITIS.  213 

Varieties It  may  exist  in   acute   or  chronic  form,  either  of  which 

types  may  appear  originally  or  be  the  result  one  of  the  other.  The  acute 
form  may  be  excited  by  some  special  cause  and  rapidly  pass  into  the 
chronic  ;  or,  originating  as  a  low  grade  of  inflammation,  the  disease  may 
at  any  time  take  on  the  characters  of  virulence  and  acuity.  Two  sub- 
divisions of  simple  vaginitis,  the  recognition  of  which  at  the  bedside 
constitutes  an  important  point,  are,  primary  and  secondary.  Sometimes 
the  disease  exists  as  a  primary  lesion,  but  very  commonly  it  depends  upon 
the  excoriating  properties  of  a  fluid  discharged  by  the  mucous  membrane 
of  the  uterus.  Under  these  circumstances  no  treatment  addressed  to  the 
vaginal  surface  will  effect  a  cure,  for  even  if  the  disorder  existing  there 
be  removed,  it  must  inevitably  return  so  long  as  the  cause  which  origi- 
nally produced  it  remains. 

Causes In  the  great  majority  of  instances  this  affection,  more  par- 
ticularly in  its  chronic  form,  depends  upon  a  discharge  from  the  uterus, 
to  which  it  is  secondary.  It  may,  however,  arise  from  any  of  the  following 
exciting  influences: — 

Exposure  to  cold  and  moisture  ; 

Injury  from  pessaries  or  coition  ; 

Disordered  blood  states,  as  those  of  phthisis  and  the  exanthemata ; 

Retained  and  putrefying  secretions  ; 

Chemical  agents  ; 

Parturition. 

After  matrimony  the  acute  form  is  not  unfrequently  excited,  and  in 
prostitutes,  whose  occupation  involves  an  abuse  of  sexual  intercourse,  it 
is  quite  common. 

A  bit  of  sponge,  or  other  substance  which  retains  the  natural  secretions, 
left  in  the  vagina  until  putrefaction  occurs,  will  often  induce  the  affection, 
and  three  of  the  most  virulent  cases  that  I  have  ever  seen  were  caused 
by  contact  of  a  solution  of  chromic  acid  with  the  vaginal  walls  in  making 
an  application  to  the  uterus. 

Pathology — At  the  commencement  of  the  disease,  the  mucous  mem- 
brane of  the  vagina  becomes  highly  vascular  and  its  arterioles  are  dis- 
tended. There  is  a  rapid  moulting  of  epithelium,  so  that  abrasions  often 
exist,  and  at  times  follicular  ulcerations  and  diphtheritic  deposits  make 
their  appearance.  Sometimes,  though  rarely,  the  epithelium  lining  of  the 
vagina  is  thrown  off  entire,  constituting  a  cast  or  mould  of  the  canal  very 
similar  in  character  to  the  dysmenorrhoeal  membrane  which  is  occasion- 
ally expelled  from  the  uterus. 

In  very  severe  cases  the  inflammatory  action  passes  down  into  the  sub- 
mucous tissues,  and  a  true  phlegmonous  process  is  established  which  may 
result  in  abscess.  For  a  period  varying  from  fifteen  to  thirty  hours  after 
the  inception  of  the  disease,  the  natural  secretion  of  the  part  is  checked  ; 


214 


VAGINITIS, 


then  pus  of  acrid  and  offensive  character  pours  forth  freely,  which,  in  a 
week  or  ten  days,  is  replaced  by  muco-purulent  material.  This  discharge 
is  found  to  consist  of  serum,  large  numbers  of  epithelial  cells,  pus,  blood- 
globules,  and  an  infusorial  animalcule  called  the  trichomonas  vaginalis  by 
M.  Donne,  who  first  described  it.  By  some  the  last  has  been  regarded  as 
ciliated  epithelium  separated  from  the  uterus,  but  it  is  probably  an  ani- 
malcule which  exists  in  vaginal  mucus  of  unhealthy  character.  M.  Donr.6 
at  first  regarded  it  as  characteristic  of  specific  vaginitis,  but  subsequently 
renounced  the  view. 

Symptoms Acute  vaginitis  manifests  itself  by  the  following  symp- 
toms : — 

A  sense  of  heat  and  burning  in  the  vagina ; 
Aching  and  weight  at  the  perineum  ; 
Frequent  desire  for  micturition; 
Profuse,  purulent  discharge  of  offensive  character; 
Violent  pelvic  pain  and  throbbing; 
Excoriation  of  the  parts  around  the  vulva. 
In  the  chronic  form  the  disease  shows  the  same  symptoms,  though  with 
much  less  severity.     In  very  mild  cases,  only  a  slight  itching  or  burning 
sensation  is  experienced,  with  discharge  of  the  leucorrhceal  matter. 

Physical  Signs When   the  inflammation  is  acute  the  labia  are  found 

swollen  and  tense,  the  mucous   membrane  of  the  vaginal  canal  red  and 

covered  with  pus,  and  the  animal  heat 
very  much  increased.  Introduction  of 
the  finger  produces  great  pain,  and  of- 
ten cannot  be  tolerated.  As  the  labia 
are  separated  a  flow  of  fetid  muco-pus 
is  discharged.  If  the  canal  be  explored 
by  means  of  the  speculum,  its  surface 
will  be  found  congested,  while  at  nu- 
merous points  abrasions,  and  perhaps 
follicular  ulcerations,  will  be  noticed. 
The  inflammatory  appearances  of  the 
vagina  will  be  seen  to  have  extended 
to  the  cervix  uteri,  and  very  generally 
from  the  os  will  be  found  to  hang  a 
plug  of  mucus  secreted  by  the  irritated, 
or  even  inflamed,  Nabothian  follicles. 

Prognosis In    its    acute    form    it 

usually  runs  its  course  in  about  two 
week.-.  In  the  chronic  form  it  lasts  for  an  indefinite  time,  often  subsiding 
into  ordinary  vaginal  leucorrhoea,  or  rather  into  a  state  of  which  this  is 
the  only  prominent  symptom. 


Fig.  80. 


'$& 


Epithelium  in  all  stages  of  development, 
in  simple  vaginitis.  220  diameters.  (T. 
Smith.) 


SPECIFIC    VAGINITIS,    OR    GONORRHOEA.  215 

Differentiation — Simple  vaginitis  may  be  confounded  with — 
Gonorrhoea; 

Endometritis; 

Pelvic  abscess ; 

Granular  degeneration  of  cervix. 
From  the  first  the  differentiation  is  always  difficult  and  frequently  im- 
possible. The  means  by  which  it  may  sometimes  be  accomplished  will  be 
mentioned  in  the  article  relating  to  Specific  Vaginitis.  From  the  three 
remaining  affections  it  is  readily  distinguishable  by  the  speculum  and 
vaginal  touch.  An  error  will  be  committed  only  when  the  practitioner  is 
not  mindful  of  the  possibility  of  its  occurrence,  and  draws  his  conclusions 
from  insufficient  data.  I  have  seen  two  cases  of  profuse  and  obstinate 
vaginal  discharge  regarded  as  the  result  of  vaginitis,  which  were  in  reality 
produced  by  pelvic  abscesses  that  emptied  their  contents  into  the  upper 
part  of  the  canal.  An  element  in  such  cases  calculated  to  mislead  a  super- 
ficial examiner  is  the  fact  that  vaginitis  does  really  exist  to  a  limited 
extent  as  a  result  of  the  purulent  flow  from  the  abscess.  This  remark 
likewise  holds  true  in  reference  to  endometritis  and  granular  degeneration. 

Complications Vaginitis  sometimes  produces  violent  urethritis,  and 

less  frequently  results  in  endometritis,  Fallopian  salpingitis,  and  pelvic 
peritonitis. 

Specific  Vaginitis,  or  Gotwrrhcea. 

Definition This  variety  of  the  affection  consists  in   inflammation  of 

the  vulva,  vagina,  and  urethra,  arising  from  a  specific  contagion  which  is 
transmitted  by  a  yellow,  purulent  discharge. 

Pathology. — The  purulent  material  which  is  the  contagious  element, 
after  remaining  for  some  time  in  contact  with  the  vaginal  walls,  excites  in 
their  investing  mucous  membrane  an  active  hyperemia  which  results  in 
heat,  swelling,  pain,  and  an  ichorous  and  abundant  purulent  secretion. 
This  inflammation  may  be  simulated  by  simple  acute  vaginitis,  but  its 
most  characteristic  features  are  usually  excited  by  the  contagious  influence 
just  alluded  to.  The  disease  may  affect  all  the  localities  above  mentioned 
at  the  same  time,  but  very  often  it  is  limited  to  the  upper  part  of  the 
vagina,  to  the  vulva,  or  to  the  urethra.  In  some  cases  it  is  for  a  length 
of  time  concealed  in  the  vaginal  cul-de-sac,  no  other  part  of  the  vagina 
being  affected.  This  fact  explains,  says  Alphonse  Guerin,1  how  women 
apparently  healthy  transmit  gonorrhoea. 

Causes As   there  is  but  one  cause  for  scarlet  fever,  for  measles,  and 

for  variola,  namely,  absorption  of  a  specific  poison  or  contagious  material, 
so  is  there,  it  appears  to  me,  but  one  cause  for  gonorrhoea.  It  is  true 
that  simple  acute  vaginitis  may  simulate  gonorrhoea  so  closely  that  the 

1  Maladies  des  Organes  Genitaux,  p.  285. 


216  VAGINITIS. 

most  experienced  observer  will  be  foiled  in  diagnosis,  but  this  fact  does 
not  prove  the  diseases  to  be  identical.  The  poison  of  gonorrhoea  produces 
inflammatory  results  as  a  certain  consequence  of  contact;  the  causes  of 
acute  vaginitis  produce  them  as  an  accident  which  probably  in  a  different 
state  of  the  patient's  system  would  not  have  occurred.1 

Symptoms. — The  symptoms  of  this  variety  of  vaginitis  differ  very  little, 
indeed  in  many  cases  not  at  all,  from  those  of  the  simple  acute  form. 
They  may  be  thus  enumerated : — 

Heat  and  burning  in  the  vagina; 

Aching  and  sense  of  weight  at  the  perineum  ; 

Frequent  desire  for  micturition  ; 

Scalding  in  the  passage  of  urine; 

Profuse  purulent  leucorrhoea  of  offensive  character; 

Violent  pelvic  pain  and  throbbing; 

Excoriation  of  the  parts  around  the  vulva. 

Physical  Signs The  vulva,  vagina,  and  urethra  will  be  found  swollen, 

tense,  red,  and  hot.  In  the  beginning  they  are  unnaturally  dry,  but  very 
soon  a  profuse  secretion  bathes  them  with  a  creamy  pus,  sometimes  streaked 
with  blood.  Should  the  affection  have  exerted  its  influence  chiefly  upon 
the  vulva,  pruritus,  excoriation,  and  intense  heat  will  be  observed.  Should 
the  urethra  be  chiefly  or  solely  diseased,  instances  of  which  are  recorded 
by  Ricord  and  Cullerier,  the  most  violent  scalding  upon  the  passage  of 
urine  will  especially  annoy  the  patient. 

Differentiation — It  will  be  seen,  from  what  has  been  already  stated, 
that  the  differentiation  of  this  disease  from  simple  acute  vaginitis  must  be 
extremely  difficult.  In  many  cases  it  is  impossible,  for  there  are  no  signs 
which  can  be  regarded  as  positively  conclusive.  The  trichomonas  vagi- 
nalis, once  supposed  by  Donne  to  be  pathognomonic  of  specific  vaginitis, 
is  now  known  to  exist  in  the  pus  of  that  which  is  simple;  and  urethritis, 
formerly  viewed  as  diagnostic  by  many,  is  sometimes  a  complication  of 
the  simple  form  and  is  sometimes  absent  in  the  specific. 

The  following  are  the  symptoms  which  should  lead  us  strongly  to  sus- 
pect the  specific  nature  of  a  case  : — 

Great  virulence  and  acuity  in  development  ; 

Development  in  a  woman  previously  free  from  vaginal  discharges ; 

Marked  urethral  complication  ; 

Copious  purulent  discharge  ; 

Transmission  to  the  male  from  coition. 
Although  it  is  true  that  in  many  cases  these  symptoms  will  render  us 

1  This  view  is  denied  by  many  of  the  best  authorities,  who  regard  gonorrhoea  as 
having  nothing  specific  about  its  nature.  At  the  same  time  that  I  have  no  wish 
to  ignore  the  opinion  with  which  mine  conflicts,  I  have  preferred  to  give  my  own 
impressions  without  discussing  the  matter. 


SPECIFIC    VAGINITIS,    OR    GONORRHOEA.  217 

certain  in  our  conclusions,  in  many  others  they  will  exist  in  cases  certainly 
of  non-specific  character.  I  have  on  two  occasions  seen  them  all  attend 
cases  of  vaginitis,  excited  by  accidental  contact  of  chromic  acid  with  the 
vaginal  walls. 

Course,  Duration,  and  Termination — The  duration  of  the  disease  will 
depend  in  great  degree  upon  the  character  of  the  treatment  adopted. 
Under  a  proper  management  even  a  severe  case  may  often  he  cured  in  from 
two  to  three  weeks,  but  if  neglected,  it  may  continue  for  months  and  per- 
haps years.  The  morbid  action  passing  up  into  the  uterus  may  exist  as 
an  endometritis  long  after  the  vaginal  trouble  has  disappeared  ;  or  it  may 
pass  into  the  bladder  and  excite  cystitis  ;  or  down  their  narrow  ducts  into 
the  vulvo- vaginal  glands. 

Dr.  Noeggerath,  in  1873,  published  a  remarkable  paper  on  "  Latent 
Gonorrhoea  in  the  Female  Sex,"1  in  which  he  declares,  that  certain  morhid 
phenomena  in  the  female  organs,  which  have  hitherto  been  considered  as 
separate,  and  treated  independently,  possess  a  common  basis  from  which 
they  collectively  and  separately  take  their  origin — this  being  nothing  more 
nor  less  than  gonorrhoea.  "  I  have,"  he  says,  "  undertaken  to  show  that 
the  wife  of  every  husband,  who,  at  any  time  of  his  life  before  marriage, 
has  contracted  a  gonorrhoea,  with  very  few  exceptions,  is  affected  with 
latent  gonorrhoea,  which  sooner  or  later  brings  its  existence  into  view 
through  some  one  of  the  forms  of  disease  about  to  be  described. 
I  believe  I  do  not  go  too  far  when  I  assert  that  of  every  100  wives  who 
marry  husbands  who  have  previously  had  gonorrhoea,  scarcely  10  remain 
healthy ;  the  rest  suffer  from  it  or  some  other  of  the  diseases  which  it  is 
the  task  of  this  paper  to  describe.  And,  of  the  ten  that  are  spared,  Ave 
can  positively  aifirm  that  in  some  of  them,  through  some  accidental  cause, 
the  hidden  mischief  will  sooner  or  later  develop  itself." 

The  diseases  to  which  this  author  refers  as  remote  consequences  of  latent 
gonorrhoea  are  perimetric  inflammations,  both  acute  and  chronic,  ovaritis, 
and  catarrh  of  the  genital  tract.  These  when  once  excited  are,  he  de- 
clares, incurable,  and  render  the  life  of  the  female  one  of  misery  and 
danger.  These  women  rarely  become  pregnant,  or,  if  they  do  so,  either 
miscarry  or  bear  only  one  child.  To  sustain  this  assertion  he  gives  the 
statistics  of  81  cases,  of  which  31  only  became  pregnant.  Of  the  31,  only 
23  went  to  full  term  ;  3  were  prematurely  delivered,  and  5  aborted.  Of 
the  23  who  went  to  full  term,  12  had  one  child  each  during  married  life  ; 
7  had  two  children  each  ;  3  had  three ;  1  had  four  ;  and  among  the  23 
women  there  were  five  abortions.  He  asserts  that  although  apparently 
cured,  gonorrhoea  may  exist  both  in  the  male  and  female  an  entire  lifetime 
in  a  latent  form,  which  may  at  any  moment  burst  forth  into  acute  gonor- 
rhoeal  inflammation,  or  excite  serious  uterine  or  periuterine  inflammation. 

1  Die  Latente  Gonorrlioe  im  Weiblichen  Geschlecht.     Bonn. 


218  VAGINITIS. 

Since  the  appearance  of  these  views  I  have  considered  this  subject  very 
carefully.  While  I  admit,  that  even  years  after  a  gonorrhoea  has  been 
considered  cured  some  lurking  infectious  element  dammed  up  perhaps  be- 
hind a  stricture  may  transmit  the  disease,  I  have  failed  to  get  evidence 
of  the  truth  of  Dr.  Noeggerath's  assumptions  as  to  the  universality  of  such 
transmission  of  disease.  Were  they  true  indeed,  it  appears  to  me  that  a 
healthy  woman  would  be  a  rare  exception  to  a  very  general  rule. 

Complications The  complications  of  gonorrhoea  in    the  female   are 

numerous  and  important.  The  disorder  sometimes  becomes  an  exceed- 
ingly grave  one,  and,  in  some  instances,  destroys  life.  It  may  induce  the 
following  results : — 

Buboes ; 

Vulvar  abscesses ; 

Cystitis ; 

Inflammation  of  vulvo-vaginal  glands  ; 

Endometritis  ; 

Fallopian  salpingitis ; 

Pelvic  peritonitis. 
Mr.   Salmon,1  who  first  drew  attention   to   inflammation  of  the  vulvo- 
vaginal glands  as  a  result  of  the  disease  which  we  are  considering,  declares 
that  it  is  quite  common. 

The  passage  of  the  disordered  action  into  the  uterus,  through  the  tubes, 
and  into  the  peritoneum  is  the  most  dangerous  of  all  its  consequences,  and 
produces  great  risk  to  life  from  the  pelvic  peritonitis  which  it  excites. 

Granular  Vaginitis. 

Definition  and  Synonyms. — This  variety  of  vaginitis  was  first  described 
by  Kicord,  under  the  name  of  Psorolytrie.  Jn  1844,  M.  Deville,2  a  pupil 
of  Kicord,  described  it  fully,  and  it  was  subsequently  treated  of  by  Blatin, 
Guerin,  and  others,  under  the  names  of  papular,  glandular,  and  granular 
vaginitis. 

Pathology. — By  these  writers  it  was  regarded  as  an  hypertrophy  of  the 
muciparous  follicles,  lying  embedded  between  the  rugae  of  the  vagina. 
This  hypertrophy,  it  was  thought,  was  generally  the  result  of  pregnancy, 
though  it  was  admitted  that  it  might  arise  from  simple  or  specific  vaginitis. 
Manv  recent  writers  deny  the  existence  of  this  variety  of  vaginitis,  and 
view  it  only  as  an  hypertrophy  of  vaginal  papilla?,  the  result  of  the  forms 
of  the  affection  already  mentioned.  Thus  Dr.  Bumstead,5  in  speaking  of 
granulations  found  in  the  vagina  as  a  result  of  vaginitis,  says,  "  They  have 
been  erroneously  regarded  by  Dr.  Deville  as  peculiar  to  the  vaginitis  of 

1  Burastead  on  Veneral  Dis.,  p.  172. 
*  Arcliiv.  de  Med.,  4th  series,  t.  v. 
»  Op.  cit. 


GRANULAR    VAGINITIS.  219 

pregnant  women."  Scanzoni1  and  West2  both  deny  its  existence,  and 
upon  the  same  ground,  viz.,  the  fact  that  Mandl  and  Kolliker  have  dis- 
covered very  tew  mucous  follicles  in  the  vaginal  mucous  membrane. 
When,  however,  in  opposition  to  the  negative  fact  that  these  excellent 
observers,  supported  by  Robin  and  Sappey,  have  not  discovered  these 
glands,  is  arrayed  the  positive  fact  that  Huschke,  Jamain,  Richet,  Bec- 
querel,  Guerin,  and  others  have  done  so,  the  grounds  for  denial  must  be 
admitted  to  be  insufficient.  Even  if  such  evidence  of  the  propriety  of 
admitting  this  variety  of  vaginitis  did  not  exist,  clinical  research  would 
corroborate  the  truthfulness  of  the  deductions  of  M.  Deville. 

The  disease  is  characterized  by  hemispherical  granulations,  about  as 
large  as  half  a  millet-seed,  scattered  thickly  over  the  mucous  membrane 
of  the  vagina  and  over  the  cervix  uteri.  This  variety  of  the  disease  ap- 
pears to  bear  the  same  relation  to  simple  vaginitis  that  follicular  vulvitis 
does  to  the  purulent  form  of  that  affection.  I  once  saw  a  case  of  granular 
vaginitis,  so  striking  in  its  features  that  the  attending  physician  had  ex- 
pressed to  the  patient's  family  his  fears  that  malignant  disease  was  devel- 
oping. He  became  at  once  convinced  of  his  grave  error,  when  shown  a 
description  of  the  disease  which  really  existed,  and  with  which  he  had 
never  before  met.  Although  I  believe  in  the  validity  of  this  variety  of 
vaginitis,  I  must  declare  that  I  have  rarely  met  with  it  out  of  the  condi- 
tion of  pregnancy. 

Causes The  glandular  hypertrophy  which  gives  to  the  disease  its  cha- 
racteristic features  and  name,  generally  results  directly  from  pregnancy, 
though  it  may  be  produced  by  either  simple  or  specific  vaginitis.  Some 
women  suffer  from  it  in  successive  pregnancies. 

Symptoms — It  demonstrates  its  presence  by  the  symptoms  already  re- 
corded as  characteristic  of  simple  and  specific  vaginitis.  With  these, 
pruritus  vulvae  and  a  lichenous  eruption  about  the  pubesareapt  to  appear. 
As  parturition  comes  on  and  puts  an  end  to  pregnancy,  it  usually  disap- 
pears, very  often  without  any  treatment  whatever. 

Treatment  of  Vaginitis. — The  treatment  of  the  various  forms  of  this 
disease  is  so  similar  that  it  may  be  described  under  one  head,  modifications 
being  suggested  for  those  cases  which  have  assumed  a  subacute  or  chronic 
aspect.  If  the  case  be  one  of  acute  character,  the  patient  should  be  kept 
perfectly  quiet  in  bed,  and  locomotion  and  sexual  intercourse  strictly  in- 
terdicted. Pain  should  be  relieved  by  opiate  or  other  anodyne  supposi- 
tories placed  in  the  rectum,  and  febrile  action  prevented  or  combated  by 
mild,  unstimulating  diet  and  refrigerants.  Every  fifth  or  sixth  hour  the 
patient,  placing  under  the  buttocks  a  bed-pan,  upon  which  she  lies,  and 
between  the  thighs  a  vessel  of  warm  water,  should,  by  means  of  a  syringe, 

1  Diseases  of  Females,  Am.  ed.,  p.  529. 

2  Diseases  of  Women,  Eng.  ed.,  p.  640. 


220  ATRESIA  OF  THE  GENITAL  TRACT. 

throw  a  steady  stream  against  the  cervix  uteri  for  fifteen  or  twenty  minutes, 
or  even  for  a  longer  time.  The  methods  most  appropriate  for  syringing 
the  vagina  are  fully  described  in  chapter  four.  The  bowels  should  be 
kept  in  a  lax  condition  by  saline  cathartics,  and  the  ardor  urinae  relieved 
by  the  use  of  alkaline  diuretics.  Should  inflammatory  action  run  very 
high,  and  much  pain  be  experienced,  great  benefit  will  be  derived  from 
the  free  administration  of  opium,  which  should  be  given  until  complete 
quiescence  of  the  nervous  system  is  accomplished. 

When  the  severity  of  the  symptoms  has  been  relieved  by  this  combi- 
nation of  general  and  local  means,  Sims's  small  speculum  should  be  passed, 
the  cervix  and  vaginal  walls  cleansed  with  absorbent  cotton,  the  whole 
canal  washed  over  with  a  solution  of  nitrate  of  silver,  9j  to  3j  of  water, 
and  a  tampon  of  carbolized  cotton  soaked  in  glycerine  applied,  so  as  to 
prevent  all  contact  of  the  opposing  walls.  This  should  be  renewed  once 
in  every  twenty-four  hours.  But  lengthy  renewal  will  not  be  found  neces- 
sary, for  cure  will,  as  a  rule,  very  soon  occur. 


CHAPTER    XIV. 

ATRESIA  OF  THE  GENITAL  TRACT  AND  RETENTION  WITHIN  IT  OF 
MENSTRUAL  BLOOD  AND  OTHER  FLUIDS. 

Definition  and  Synonyms The  term  atresia,  derived  from  o,  privative, 

and  rpaw,  "  I  perforate,"  signifies  an  imperforate  condition,  and  should  in 
its  strict  import  be  limited  to  complete  closure  of  an  aperture  or  canal. 
Any  obliteration  or  occlusion  which  is  so  extreme  as  to  remove  the  case 
from  the  class  of  strictures,  and  yet  is  not  complete,  should  be  styled  ste- 
nosis. The  genital  canal  of  the  female  may  be  imperforate  at  the  vulva, 
in  the  vagina,  or  in  the  canal  of  the  uterus  itself. 

Any  one  of  these  atresia?  may  act  as  a  barrier  to  the  escape  of  menstrual 
blood,  and  create  a  dangerous  retention  of  that  fluid  with  coincident  over- 
distention  of  the  vagina,  uterus,  and  Fallopian  tubes,  which  may  become 
so  excessive  as  to  end  in  rupture,  peritonitis,  and  death.  As  this  is  the 
chief  relation  in  which  they  are  to  be  considered,  it  seems  best  to  study 
the  varieties  of  atresia  under  one  head. 

Congenital  atresia  never  attracts  notice  until  puberty  has  arrived,  and 
then  an  examination  is  instituted  on  account  of  non-appearance  of  the 
menstrual  flow,  the  presence  of  an  abdominal  tumor  caused  by  uterine  or 
vaginal  distention,  or  the  suspicion  of  pregnancy,  some  of  the  prominent 
signs  of  which  are  present  under  these  circumstances.  Acquired  atresia 
is  suspected  for  the  same  reasons. 


ATRESIA    OF   THE    UTERUS.  221 

In  general  terms  it  may  be  stated  that  the  higher  up  the  atresia  be,  the 
greater  the  danger  arising  from  its  existence.  Thus,  an  atresia  of  the 
hymen  is  the  least  dangerous  of  all;  one  as  high  as  the  os  internum  uteri 
the  most  so.  The  reason  for  this  is  evident :  the  former  has  above  it,  for 
accommodation  of  retained  fluid,  the  distensible  vagina  and  cervical  canal ; 
the  latter  has  only  the  uterus  itself.  Then,  too,  distention  of  the  vagina 
produces  less  marked  influence  upon  the  Fallopian  tubes  than  that  of  the 
uterus.  Distention  of  the  latter  does  not,  it  is  now  thought,  cause  a  re- 
flux through  the  tubes,  but  creates  a  species  of  vicarious  menstruation  from 
their  walls.  This  gives  rise  to  hamiato-salpinx,  which  so  often  ends  in 
rupture  of  the  tube  that  that  accident  should  be  feared  as  one  of  the  most 
decided  dangers  connected  with  the  condition. 

This  tubal  rupture  may  occur  in  two  ways:  first,  sudden  emptying  of 
the  uterine  contents  creates  uterine  contraction  which  at  once  extends  to 
the  muscular  fibres  of  the  tubes,  and  rupture  is  the  result;  or,  previous 
peritonitis  having  fixed  the  tubes,  descent  of  the  uterus  drags  upon  them 
so  powerfully  as  to  cause  their  rupture,  or  laceration  of  the  false  membranes 
which  hold  them. 

It  must  not  be  forgotten,  however,  that,  although  it  is  an  exception  to 
the  rule,  vaginal  atresia  may  cause  distention  of  the  uterus  and  tubes  by 
gradually  dilating  the  uterine  tract,  and  before  every  operation  this  effect 
should  be  considered. 

Atresia  of  the  Uterus. 

Definition  and  Frequency. —  This  consists  in  closure  of  the  canal  of  the 
cervix  so  that  no  fluid  can  escape.  In  its  partial  form,  that  of  stenosis,  it 
is  by  no  means  rare,  but  fortunately  complete  atresia  is  decidedly  so. 

Varieties. — Uterine  atresia  may  be  either  congenital  or  acquired. 
When  it  is  congenital  it  may  exist  at  the  os  internum,  at  the  os  externum, 
or  involve  the  whole  cervical  canal.  Sometimes  the  cervix  is  exceedingly 
small  while  the  body  is  greatly  distended  by  fluids. 

"When  the  condition  is  acquired,  it  may  also  be  limited  to  one  or  both 
ora  or  involve  the  whole  extent  of  the  canal.  The  causes  which  most 
commonly  induce  it  are  the  following : — 

The  use  of  caustics  ; 

Cervical  endometritis ; 

Irritation  from  neoplasms  in  the  canal ; 

Senile  atrophy  ; 

Sloughing  after  parturition ; 

Amputation  of  uterine  neck  ; 

The  use  of  the  steel  curette. 
The  first  of  these  is  a  very   common   cause  of  severe   stenosis,  and 
sometimes  produces  even  complete  atresia.     The  second,  involving  the 
Nabothian  follicles,  sometimes  ends  in  adhesive  inflammation.    The  third 


222  ATRESIA    OF    THE   GENITAL    TRACT. 

I  have  seen  produce  the  condition  in  three  cases.  The  fourth  is  so  very 
common  in  old  age  that  Hennig  declares,  that,  out  of  one  hundred  women 
who  had  passed  fifty  years  of  age,  about  twenty-eight,  over  a  quarter, 
suffered  from  it.  The  fifth  and  sixth  are  often  met  with  as  causes,  and  the 
seventh  I  once  had  occur  in  my  own  practice. 

Results. —  It  might  at  first  thought  be  supposed  that  uterine  atresia  occur- 
ring after  the  menopause  would  be,  as  it  usually  is  before  puberty,  a  matter 
of  no  moment.  As  a  rule  this  is  so,  but  there  are  exceptions  to  both  rules. 
In  the  old  woman  a  watery  secretion  sometimes  takes  place,  giving  rise  to 
hydrometra;  suppurative  action  may  occur,  creating  pyometra ;  and  de- 
composition of  the  imprisoned  fluid  gives  rise  very  rarely  to  a  develop- 
ment of  air,  physometra.  Very  rarely  hydrometra  is  found  before  puberty 
and  hematometra  in  old  women. 

The  evils  which  result  from  uterine  atresia  are — 

Haematometra ; 

Hematosalpinx ; 

Hydrometra. 
And  the  consequences  of  these,  if  they  be  left  uninterfered  with,  may 
be— 

Peritonitis ; 

Pelvic  hematocele ; 

Rupture  of  the  vagina,  uterus,  or  tubes; 

Septicemia. 
Prognosis. —  Whatever  course  be  pursued,  in  a  patient  suffering  from 
uterine  atresia  with  retention  of  menstrual  blood,  the  prognosis  is  neces- 
sarily a  grave  one.  Non-interference  may,  and  probably  sooner  or  later 
will,  end  in  the  development  of  one  of  the  accidents  just  recorded.  Sur- 
gical interference,  on  the  other  hand,  is  attended  by  the  dangers  of  rupture 
of  the  tubes,  laceration  of  the  false  membranous  attachments,  and  the 
development  of  septicemia  from  the  admission  of  air  to  the  distended 
uterine  cavity. 

Diagnosis  and  Differentiation. —  It  is  sometimes  exceedingly  difficult 
to  differentiate  retained  menstrual  blood  in  the  uterine  tract  from  fibrous 
tumors,  malignant  growths,  ovarian  cysts,  hematocele,  and  pregnancy. 
The  rational  signs  which  enable  us  to  do  so  are  these :  in  all  but  the  last, 
menstruation  is  commonly  increased,  while  here  it  is  suppressed  ;  the  tumor 
is  surely  uterine  and  not  ovarian,  retro-uterine,  or  ante-uterine ;  it  has 
come  on  slowly,  and  not  suddenly  as  the  tumor  of  hematocele  does,  and 
at  every  monthly  epoch  an  increase  of  inconvenience  is  noticeable  from 
its  presence.  Physical  signs  yield  more  important  results  still.  If  an 
attempt  be  made  cautiously  to  pass  the  uterine  sound  or  probe,  the  cervical 
canal  will  be  found  to  be  closed.     This  constitutes  the  crucial  test. 

The  diagrams,  Figs.  81  and  82,  show  the  varieties  of  hematometra 
occurring  in  cervical  atresia. 


ATRESIA    OF    THE    UTERUS. 


223 


Fig.  83  presents  an  instance  of  atresia  in  one  of  the  uteri  in  a  case  of 
double  uterus,  the  other  being  free  to  perform  all  its  functions. 


Fir..  81. 


Fia.  82. 


Uterine  atresia  at  os  externum. 


Uterine  atresia  at  os  internum. 


In  the  last  case  menstruation  would  be  regular,  the  uterus  be  susceptible 
of  recognition  by  conjoined  manipulation  and  the  passage  of  the  sound  to 


Fig.  83. 


Atresia  in  one-half  of  a  double  uterus. 


the  fundus,  while  one  half  of  the  abnormally  developed  organ  would  present 
the  large  tumor  seen  in  the  diagram.  Diagnosis  would  be  possible  here 
only  by  very  careful  conjoined  manipulation. 


224 


ATRESIA  OF  THE  GENITAL  TRACT. 


Atresia  of  the  Vagina. 

Like  the  uterus  the  vagina  is  in  foetal  life  created  from  the  approxima- 
tion and  amalgamation  of  the  Mullerian  ducts  upon  the  median  line.  In 
the  former  a  great  variety  of  congenital  malformations  are  the  result  of 
arrest  of  development  of  these  parts.  So  is  it  also  with  the  latter;  the 
chief  of  its  anomalies  being  double,  unilateral,  diminutive,  and  rudimen- 
tary vagina,  or  no  vestige  of  it  may  exist.  The  condition  which  is  now 
to  engage  our  attention  may  be  due  to  such  congenital  arrest  of  develop- 
ment or  to  accidental  causes  developing  after  adult  life  has  been  reached. 

History — Hippocrates1  refers  to  this  condition  as  a  result  of  labor ; 
Aristotle  speaks  of  the  accidental  and  congenital  varieties  ;  Celsus  devotes 
a  chapter  to  it,  and  it  claims  attention,  as  we  come  down  to  subsequent 
times,  from  Aetius,  Avicenna,  Lanfranc,  Wierus,  Ruysch,  Mauriceau,  and 
Roonhuysen.  Heister  and  Boyer  advanced  our  knowledge  of  it,  but  it 
was  left  for  the  daring  enterprise  of  Dupuytren,  Amussat,  and  Debrou,  to 
place  its  cure  among  the  achievements  of  modern  surgery. 


Fig.  84. 


Fig.  85. 


The  vagina  distended  by  blood  from  imper- 
forate hvmen. 


Vagina  and  uterus  both  distended  with  blood  in 
consequence  of  an  impervious  hymen. 


Varieties. — There  may  be  no  trace  of  the  canal,  the  ducts  of  Muller 
seeming  to  have  failed  entirely  to  develop ;  there  may  be  a  distinct  fibrous 
cord  marking  the  site  which  it  should  have  occupied,  some  slight  develop- 


1  Puesch,  De  l'Atresie  des  Voies  Gen.  de  la  Femme. 


ATRESIA    OF    THE    VAGINA.  225 

ment  appearing  to  have  occurred ;  development  may  exist  for  some  dis- 
tance up  the  canal,  failure  having  taken  place  above;  oroneMiilleriauduct 
has  developed  in  part  above  and  another  below,  giving  two  cul-de-sacs 
separated  from  each  other  by  impervious  tissue.  The  whole  canal  is  not 
rarely  well  developed,  while  the  hymen  guards  its  outlet  as  an  unyielding 
and  completely  closed  obturator  membrane.  The  last  of  these  vaginal 
atresia),  and,  fortunately,  the  most  frequently  met  with,  is  depicted  in 
Figs.  84  and  85. 

Not  only  is  the  operation  for  relief  in  such  a  case  much  more  simple 
than  in  other  varieties  of  atresia,  the  uterus  is  usually  not  involved  in  the 
dilatation  and  the  danger  of  trouble  after  operation  is  not  so  great. 

Pathology. —  As  a  result  of  injury  from  mechanical,  chemical,  or  patho- 
logical agencies,  a  vagina  once  fully  developed  may  close  from  adhesion 
of  its  walls;  its  calibre  may  be  diminished  by  absolute  removal  of  its 
component  structures  in  consequence  of  ulceration  or  sloughing;  or  the 
other  parts  of  the  female  genital  system  may  go  on  to.  full  development 
while  this  is  arrested  in  its  growth  and  remains  a  fibrous  cord  instead  of  a 
distensible  canal. 

Causes. — The  following  special  causes  may  be  enumerated  as  productive 
of  it  :— 

Impervious  hymen ; 

Arrest  of  development  of  vagina ; 

Prolonged  and  difficult  labor  ; 

Chemical  agents  locally  applied  ; 

Mechanical  agencies  exciting  inflammation ; 

Sloughing,  the  result  of  impaired  vitality ; 

Syphilitic  or  other  extensive  ulcerations. 
One  of  the  cases  which  have  come  under  my  observation  resulted  from 
syphilis;  several  from  prolonged  labor;  one  from  the  accidental  passage 
of  a  sharp  bit  of  wood  up  the  vagina  ;  another  from  retention  of  the  foetal 
body  for  two  hours  after  delivery  of  the  head  'r  and  one  from  a  tampon  of 
cotton  saturated  with  persulphate  of  iron.  Among  the  causes  of  sloughing 
from  impaired  vital  force  should  be  especially  mentioned  the  continued  and 
eruptive  fevers,  typhus  fever,,  scarlatina,  variola,  etc. ;  and  cholera  as  a 
cause  of  the  accident  is  referred  to  by  M.  Courty.  Dr.  Trask,  of  Astoria, 
N.  Y.,  has  written  an  excellent  article  upon  this  subject,  his  conclusions 
being  based  upon  thirty -six  cases,  of  which  fifteen  were  due  to  prolonged 
labor. 

Symptoms. — The  disorder  will  demonstrate  its  existence  only  by  inca- 
pacitating the  vaginal  canal  for  its  important  functions,  copulation  and 
transmission  of  menstrual  blood.  Should  it  occur  in  one  too  young  or  too 
old  to  require  such  functions  from  the  vagina,  no  suspicion  will  be  aroused 
as  to  its  existence.  The  notice  of  the  practitioner  will  generally  be  called 
to  the  patient  by  amenorrhoea  or  by  an  inability  to  perform  the  act  of 
15 


226  ATRESIA    OF    THE   GENITAL    TRACT. 

coition.  Should  the  menstrual  hemorrhage  have  taken  place,  a  large 
amount  of  blood  will  generally  be  found  confined  above  the  constricted 
part  of  the  canal,  and  violent  contractions  will  have  demonstrated  the 
efforts  which  the  parts  have  made  to  expel  the  accumulation.  Besides 
these,  no  other  rational  signs  will  show  themselves,  but  they  will  be  suffi- 
cient to  urge  upon  the  attendant  the  necessity  for  a  physical  exploration. 

Physical  Signs. —  The  patient  being  placed  upon  the  back,  and  vaginal 
touch  attempted,  entrance  of  the  finger  into  and  up  the  vagina  will  be 
found  to  be  impossible.  Investigation  will  prove  that  this  is  not  due  to 
vaginismus,  or  adhesion  of  the  labia  majora,  and  rectal  touch  will,  in  cases 
involving  the  vagina,  usually  discover  that  canal  running  up  the  pelvic 
cavity  as  a  fibrous  cord,  though  sometimes  no  trace  of  it  will  be  found. 

Results. —  From  the  mere  occlusion  of  the  vagina  there  is  no  imme- 
diate or  direct  derangement.  But  in  cases  where  menstrual  blood  is 
poured  out  by  the  vessels  of  the  uterine  mucous  membrane,  and  is  accumu- 
lated at  each  monthly  epoch  in  the  portion  of  the  canal  above  the  stric- 
ture, or  in  the  uterus,  which  is  dilated  by  its  retention,  rupture  of  these 
organs  or  of  the  Fallopian  tubes  may  occur;  discharge  from  these  tubes 
into  the  peritoneum  may  take  place,  and  pelvic  hsematocele  be  the  conse- 
quence; or  the  retention  of  the  menstrual  flow  may  produce  all  those 
nervous  and  cerebral  symptoms  so  characteristic  of  such  an  occurrence. 

Prognosis. —  The  prognosis  of  these  cases,  as  regards  the  possibility  of 
removal  of  the  abnormal  state,  will  depend  upon  the  extent  and  complete- 
ness of  the  obliteration  and  destruction  of  tissue.  The  smaller  the  amouut 
of  vaginal  tissue  found  by  rectal  touch  and  examination  by  a  sound  in  the 
bladder  to  exist,  and  the  more  complete  and  extensive  the  adhesion  of 
the  vaginal  walls,  the  more  closely  will  the  case  resemble  one  of  entire 
absence  of  the  vagina.  The  prognosis  as  to  permanent  cure  will  greatly 
depend  upon  the  patient.  If  she  be  a  woman  of  good  sense  and  perse- 
verance, and  keep  up,  after  operation,  distention  by  the  vaginal  plug,  not 
for  months,  but  for  years,  the  result  is  often  a  very  good  and  permanent 
one.  If,  on  the  other  hand,  she  ignores  the  risk  attendant  upon  the  cessa- 
tion of  its  use,  contraction  will  probably  recur.  During  the  process  of 
making  a  canal  between  the  bladder  and  rectum,  one  of  these  viscera  is 
very  apt  to  be  cut  into,  or  the  peritoneum  may  be  opened  at  the  fornix 
vaginae*.  If  a  depot  of  menstrual  blood  be  reached  and  evacuated,  death 
is  by  no  means  rare  from  septicaemia,  purulent  absorption,  or  a  septic 
endometritis  which  ends  in  lymphangitis,  or  in  salpingitis  and  peritonitis. 

The  prognosis  is  greatly  governed,  too,  by  the  variety  of  atresia  with 
which  we  deal.  Occlusion  due  to  impervious  hymen  warrants  a  very 
favorable  prognosis ;  that  arising  from  accidental  causes,  likewise;  that 
from  congenital  cause  in  which  the  uterus  and  vagina  can  be  distinctly 
discovered  as  existing,  a  less  favorable  one ;  while  that  due  to  absence  of 
vagina  and  uterus,  as  far  as  clinical  observation  can  verify  the  fact,  a 


ATRESIA    OF    THE    VAGINA.  227 

well-nigh  hopeless  one.  In  other  words,  the  more  complete  the  absence 
of  vaginal  tissue  and  that  of  other  organs  of  the  pelvis,  the  more  unfavor- 
able will  be  the  prognosis  as  to  recovery  from  surgical  interference. 

Should  deformity  of  the  external  genitals  exist,  the  uterus  not  be  dis- 
coverable, and  no  signs  of  distress  at  menstrual  epochs  show  themselves, 
it  may  be  concluded  that  the  case  is  one  of  absence  of  the  vagina,  and  not 
of  complete  atresia.  But,  thanks  to  the  boldness  of  Amussat,  even 
absence  of  the  vagina  does  not  preclude  the  possibility  of  establishing  an 
artificial  canal.  The  importance  of  the  differentiation  consists  in  the 
fact  that  the  surgeon  should  in  such  a  case  be  doubly  cautious  and  circum- 
spect in  his  efforts,  and  guarded  in  his  prognosis.  It  may  at  first  thought 
appear  that  in  case  there  be  no  evidence  of  the  existence  of  uterus  or 
ovaries,  and  no  inconvenience  be  experienced  from  retention  of  menstrual 
blood,  it  would  not  become  necessary  to  resort  to  an  operation  to  render 
the  vagina  pervious.  But  so  great  is  the  unhappiness  often  resulting 
from  incapacity  of  the  woman  for  the  sexual  act,  that  this  becomes  a 
reason  for  her  to  demand  the  resources  of  art,  and  a  valid  ground  for 
interference  on  the  part  of  the  surgeon.  If  no  such  demand  is  made  for 
surgical  interference,  it  would,  in  such  a  case  as  that  just  depicted,  be  an 
unwarrantable  procedure.  Not  only  is  the  patient  exposed  to  danger 
without  sufficient  indication  ;  she  is  thus  exposed  for  the  opening  of  a 
canal  which  has  a  marked  tendency  to  close  completely. 

The  rule  with  reference  to  operation  for  atresia  due  to  congenital 
closure  or  absence  of  the  vaginal  canal  itself  should,  it  seems  to  me,  be 
this :  it  should  be  resorted  to  (a)  if  menstrual  blood  be  imprisoned ;  (b) 
if  a  uterus  can  be  distinctly  discovered  and  the  patient  be  suffering  from 
absence  of  menstruation  ;  (c)  if  the  necessity  for  sexual  intercourse  be 
imperative  :  it  should  be  avoided  unless  demanded  by  one  of  these  con- 
siderations. 

Treatment To  surgery  alone  can  we  look  for  any  hope  of  recovery  or 

of  safety  in  cases  of  atresia  of  the  female  genital  canal.  I  shall  treat  of 
this  part  of  the  subject,  as  it  applies  to  all  varieties  of  atresia. — uterine, 
vaginal,  and  their  subdivisions.  It  is  evident  that,  to  do  justice  to  it, 
operative  interference  must  be  described  as  applying  to  the  following 
cases : — 

1st.  Where  there  is  atresia  of  the  uterine  neck. 

2d.  Where  there  is  atresia  of  the  hymen  alone. 

3d.  Where  the  vaginal  canal  is  closed  only  for  a  small  portion  of  its 
course. 

4th.  Where  there  is  complete  closure  or  entire  absence  of  the  vagina. 

Where  there  is  Atresia  of  the  Uterine  Neck — The  operator  should 
decide,  by  careful  conjoined  manipulation,  as  to  the  degree  of  uterine 
distention  which  exists  above  the  cervical  closure.  If  this  be  slight,  the 
obstruction  may  at  once  be  overcome  ;   if  it  be  very  decided,  it  will  be 


228  ATRESIA  OP  THE  GENITAL  TRACT. 

safer  to  draw  off  the  fluid  gradually,  in  order  to  avoid  violent  uterine 
contractions,  which  may,  as  Barnes1  suggests,  force  fluid  from  the  cavity 
of  the  uterus  through  the  tubes,  or  affect  the  tubes  by  sympathy,  or  by 
sudden  dragging  downwards.  Let  us  suppose  that  the  uterine  tumor  is 
quite  large  ;  the  patient  should  be  placed  in  Sims's  position,  and,  his 
speculum  being  introduced,  the  cervix  uteri  should  be  caught  with  a 
tenaculum,  and  the  point  at  which  puncture  is  to  be  practised  carefully 
selected.  The  smallest  needle  of  Dieulafoy's  aspirator  should  be,  with 
the  tube  of  the  instrument  attached  to  it,  fixed  upon  this  point,  and  then, 
the  vagina  being  filled  with  carbolized  spray,  it  should  be  passed  into  the 
uterus  and  the  blood  drawn  off  by  suction.  When  the  uterine  tumor  is 
diminished  about  one-third,  the  needle  should  be  rapidly  withdrawn  and 
the  vagina  tamponed  with  carbolized  cotton,  saturated  at  the  moment  of 
use  with  carbolized  water. 

This  tampon  may  be  left  in  place  for  forty-eight  hours  and  then  re- 
moved, and  in  a  week  or  two,  as  seems  best  to  the  operator,  this  process 
of  gradual  withdrawal  of  the  retained  menstrual  blood  may  be  repeated, 
until  the  uterus  has  become  small  and  nearly  empty.  Then,  or  at  once,  in 
case  the  uterus  be  not  originally  much  distended,  the  operation  for  cure 
of  the  atresia  may  be  practised.  The  following  method  I  have  resorted 
to  in  two  cases  with  excellent  results,  and  it  appears  to  me  to  recommend 
itself  on  account  of  its  simplicity  and  safety.  The  patient  being  arranged 
as  for  aspiration  which  has  just  been  described,  under  a  very  slight  car- 
bolized spray  which  does  not  obscure  vision,  the  cervix  should  be  steadied 
by  a  tenaculum  and  along  exploring  needle  passed  into  the  uterine  cavity. 
The  sense  of  resistance  overcome,  and  the  escape  of  a  drop  of  blood  will 
assure  the  operator  of  his  success  in  reaching  it.  Then  putting  into  the 
gutter  of  the  needle  a  delicate  tenotome,  he  pushes  it  upwards  to  the  re- 
quired distance  to  open  the  canal.  This  section  is  repeated  on  the  other 
three  sides,  the  cavity  of  the  uterus  is  syringed  out  with  carbolized  water 
very  gently  forced  from  a  small  syringe  ;  a  small  glass  plug  is  inserted  in 
the  cervix,  and  the  vagina  tamponed  as  after  aspiration. 

Where   Vaginal  Atresia   is  due  to  closure  by  a  Diaphragm   or  by  the 

Hymen The  same   rule  of  practice  should  be  observed,  and  the  same 

antiseptic  precautions  adopted.  If  gradual  evacuation  be  resorted  to  and 
septic  fever  begin  to  develop,  recourse  should  at  once  be  had  to  the  rapid 
method.  Gradual  evacuation  should  be  accomplished  exactly  as  in  uter- 
ine atresia,  for  it  is  always  safe  to  conclude  that  with  vaginal  distention 
there  is  probably  uterine.  Section  of  the  hymen  may  be  practised  in  two 
ways :  first,  by  passing  the  exploring  needle,  sliding  a  knife  up  its  groove 
and  making  a  free  crucial  incision  ;  second,  by  catching  the  bulging  sep- 
tum, as  Puesch  has  advised,  and  cutting  out  a  large  circular  piece. 

>  Dis.  of  Women,  2d  Am.  ed.,  p.  214. 


ATRESIA    OF    THE    VAGINA.  220 

After  the  occluding  septum  has  been  destroyed,  the  cavity  above  should 
be  freely  syringed  out  with  carbolized  water,  and  Sims's  glass  vaginal 
plug  introduced. 

Where  there  is  entire  Closure  or  Absence  of  the   Vagina In  the  first 

case  a  hard,  fibrous  cord  will  mark  the  position  of  the  vagina;  in  the  second 
no  indication  of  it  will  be  found,  and  a  canal  must  be  created  between 
rectum  and  bladder,  out  of  a  space  occupied  by  areolar  tissue.  Should 
accumulation  of  menstrual  blood  have  occurred,  the  operation  will  prove 
much  easier  than  if  it  has  not,  for  its  greatest  difficulty  consists  in  finding 
the  cervix  uteri,  and  in  cases  of  accumulation  this  is  an  easy  matter. 

The  other  operations  for  atresia  become  insignificant  when  compared 
with  this  one,  which  as  Courty  well  observes  especially  calls  for  an  "  alli- 
ance of  caution  with  skill." 

Before  operation,  if  there  be  any  doubt  as  to  the  presence  of  the  uterus 
or  as  to  its  size  or  position,  the  hand,  except  the  thumb,  may  be  introduced 
into  the  rectum,  after  stretching  the  sphincter,  and  a  full  and  satisfactory 
exploration  made. 

If  on  account  of  great  obesity  it  be  found  impossible  to  appreciate  by 
conjoined  manipulation  the  extent  of  tissue  existing  between  the  bladder 
and  rectum,  and  consequently  in  the  course  in  which  the  vagina  is  to  be 
opened,  or  perhaps  absolutely  constructed,  the  urethra  may  be  rapidly 
distended  by  sounds  so  as  to  admit  the  finger  to  the  bladder.  Then  the 
index  and  middle  fingers  of  the  right  hand  being  carried  up  the  rectum, 
and  the  index  of  the  left  introduced  into  the  bladder,  this  important  point 
may  be  ascertained. 

Before  operating,  the  patient  should  be  anaesthetized,  and  the  bladder 
and  rectum  emptied  of  their  contents.  She  should  be  placed  in  the  li- 
thotomy position  upon  a  table  before  a  good  light,  and  the  operator  should 
have  four  assistants  at  his  disposal. 

The  operation  may  be  performed  by  two  methods :  that  of  Dupuytren 
(1818),  which  consists  of  breaking  a  passage  by  the  finger,  cutting  ob- 
structions which  cannot  thus  be  overcome,  and  syringing  out  the  cavity 
afterwards,  the  whole  operation  being  finished  at  one  sitting  ;  and  that  of 
Amussat  (1832),  which  consists  of  working  with  the  finger  and  dull  in- 
struments, overcoming  resistance  by  pressure  rather  than  by  incision,  and 
completing  the  operation  not  in  one  but  in  several  sittings. 

Dupuytren's  Operation — Barnes1  expresses  a  decided  preference  for 
this  over  Amussat's  operation,  and  my  experience  leads  me  to  agree  with 
him.      Courty2  thus  describes  Dupuytren's  procedure  : — 

'•The  procedure  devised  by  Dupuytren,  about  the  year  1817,  consists 
in    the   combined  use  of  a  cutting  instrument  and  tearing  of  the  cellular 

1  Diseases  of  Women,  p.  212,  2d  Am.  ed. 

2  Mai.  de  l'uterus,  p.  3S1.     1866. 


230  ATRESIA  OF  THE  GENITAL  TRACT. 

tissue.  It  is  accomplished  in  a  single  sitting,  and  appears  to  me  preferable 
to  the  preceding  one  (Amussat's). 

"The  following  is  the  description  of  it,  with  the  modifications  which  M. 
Puesch  has  added  : — 

"  After  having  arranged  the  woman  in  a  convenient  position,  the  blad- 
der is  emptied  by  means  of  a  male  catheter  which  is  given  to  an  assistant 
who  holds  it  turned  upwards.  It  is  not  removed  during  the  operation  ex- 
cept where  the  obliquity  of  the  part  would  render  it  troublesome.  The 
index  finger  of  the  left  hand  is  then  carried  into  the  intestine  as  far  as 
possible,  in  order  to  serve  as  a  guide  for  the  bistoury  and  at  the  same  time 
as  a  protection  to  the  rectum.  After  these  preliminary  steps  the  operator, 
placed  between  the  thighs  of  the  patient,  makes  a  transverse  incision  at 
the  centre  of  the  obstacle,  or  in  the  vulvar  orifice  if  the  vagina  is  com- 
pletely wanting  ;  if  the  cellular  tissue  is  lax,  he  can  tear  with  his  finger, 
the  sound,  or  the  handle  of  the  bistoury  the  vesical  and  rectal  walls  till  he 
reaches  the  tumor ;  if  it  is  tense  or  too  resistant,  the  surgeon  dissects  by 
gentle  efforts,  separating  the  tissues  with  the  handle  or  the  finger  rather 
than  cutting  them,  and,  if  it  be  necessary,  breaking  them  down  at  the 
edges  with  a  button  bistoury.  In  each  case  he  proceeds  slowly  and  care- 
fully, stopping  from  time  to  time  to  examine  with  the  finger  and  be  certain 
at  what  distance  those  organs  are  situated  which  it  is  necessary  to  avoid. 
When  the  canal  which  has  been  reopened  will  admit  the  index  finger 
easily,  and  when  a  more  distinct  perception  of  fluctuation  announces  the 
proximity  of  the  sanguineous  collection,  the  operator  is  warranted  in 
plunging  a  trocar  into  this,  and  the  pouring  out  of  a  syrupy,  brown  liquid, 
like  the  lees  of  wine,  will  show  that  the  end  has  been  reached.  The  pres- 
sure upon  the  uterus  is  then  stopped,  a  large  part  of  the  fluid  is  allowed 
to  flow  away  through  the  canula,  and  then,  substituting  for  this  instrument 
a  perforated  sound,  the  operator  increases  the  size  of  the  opening  by  nu- 
merous incisions  upon  its  sides  and  thus  renders  certain  the  tinal  result. 
Afterwards  he  carries  a  gum-elastic  sound  into  the  uterine  cavity,  and 
throws  through  this,  but  with  very  little  force,  several  injections  of  warm 
water.  The  dressing  having  been  finished,  the  parts  are  sponged  and 
dried,  and  the  patient  is  placed  in  a  bed  protected  by  cloths  so  as  to  pre- 
vent the  bedding  from  being  soiled  by  the  mucous  and  sanguinolent  dis- 
charges which  flow  during  the  first  days." 

Amussat's  Operation. — The  labia  being  retracted  by  the  fingers  of  two 
assistants,  holding  the  thighs,  the  finger  of  a  third,1  who  kneels  by  the  side 
of  the  operator,  is  introduced  into  the  rectum,  with  its  palmar  surface 
looking  backward.  A  steel  sound  is  then  passed  into  the  bladder,  which 
the  assistant,  on  the  left  of  the  woman,  holds  in  the  right  hand.  At  this 
moment,  this  assistant  holds  the  woman's  knee  under  his  left  arm,  retracts 

1  The  arrangement  of  assistants  is  my  own. 


ATRESIA    OF    THE    VAGINA.  231 

the  labium  by  his  left  hand,  and  holds  the  sound  in  his  right  hand.  The 
sound  he  must  press  upon  gently,  so  as  to  let  the  operator's  finger  recog- 
nize its  presence  as  it  works  its  way  up  the  vagina.  By  means  of  a  pair 
of  curved  scissors,  conducted  up  to  the  point  of  obliteration  upon  one 
finger,  the  tissue  between  the  urethra  and  rectum  should  then  be  very 
cautiously  cut,  in  a  transverse  direction,  and  the  finger  introduced  into 
the  opening  made.  This  is  really  almost  all  the  cutting  which  should  be 
done ;  the  rest  should  be  accomplished  chiefly  by  the  finger.  This,  by 
the  sense  of  touch,  tells  the  operator  exactly  how  near  he  approaches  the 
sound  in  the  bladder  on  one  side,  and  the  finger  in  the  rectum  on  the 
other.  To  one  who  has  not  tried  this  plan,  the  facility  with  which  the 
adherent  vaginal  walls  may  be  separated,  or  a  new  tract  torn  through  the 
tissues,  will  be  surprising.  Now  and  then,  the  application  of  the  scissors 
or  of  a  curved,  probe-pointed  bistoury  will  become  necessary,  but  every 
such  necessity  constitutes  an  element  of  danger. 

As  the  operator  approaches  the  regions  around  the  cervix,  he  may  be- 
come bewildered  as  to  its  position.  Under  these  circumstances,  let  him 
make  pressure  by  his  unoccupied  hand,  over  the  hypogastrium,  so  as  to 
force  the  hard  cervix  down  upon  his  finger,  or  stop  and  make  a  careful 
exploration  by  conjoined  manipulation,  two  fingers  in  the  rectum  and 
one  hand  over  the  abdomen.  Having  thus  reassured  himself  he  may  pro- 
ceed. 

However  the  operation  for  atresia  be  performed,  there  is  always  great 
danger  of  relapse,  and  unless  special  means  be  adopted  for  maintaining 
the  perviousness  of  the  canal,  it  will  probably  occur.  To  prevent  this 
unfortunate  result  the  French  operators,1  to  whom  we  are  indebted  for 
most  of  our  surgical  resources  in  this  difficulty,  used  bougies  wrapped  with 
linen,  tampons  of  lint,  and  India-rubber  bags  filled  with  air;  but  we  have 
a  much  cleaner  and  more  effectual  means  for  doing  it,  in  the  glass  vaginal 
plug  of  Sims. 

If  menstrual  blood  have  been  imprisoned  above  the  strictured  portion 
of  the  vagina,  the  canal  should,  for  a  fortnight  after  operation,  be  kept 
scrupulously  clean  by  injections  of  tepid  water  practised  twice  a  day.  If 
the  uterus  and  tubes  have  been  distended  by  retained  fluid,  the  cavity  of 
the  former  should,  just  after  the  operation,  be  carefully  washed  out  with 
tepid  water  very  slightly  impregnated  with  carbolic  acid,  tincture  of 
iodine,  or  Labarraque's  solution  of  soda,  as  advised  by  Courty.  The  pa- 
tient should  then  be  kept  as  quiet  as  possible  in  the  recumbent  posture, 
and  slightly  under  the  influence  of  opium. 

The  period  at  which  operation  should  be  resorted  to  for  congenital 
atresia  is  a  subject  of  importance.  Yelpeau  advocates  operating  in  in- 
fancy, but  Peusch,  Boyer,  and  others  regard  the  age  of  puberty  and   ap- 

1  Courty,  op.  cit.,  p.  386. 


232  ATRESIA  OF  THE  GENITAL  TRACT. 

proach  of  menstruation  as  a  more  appropriate  time.  Should  the  meno- 
pause have  arrived,  no  operation  will  be  called  for,  unless  hydrometra 
exist  or  marital  relations  demand  it. 

It  should  not  be  forgotten  that  delay  in  interference  is  often  very  dis- 
astrous during  the  period  of  menstrual  activity,  for  lives  have,  in  numer- 
ous instances,  been  destroyed  by  rupture  of  the  Fallopian  tubes,  and  even 
of  the  uterus  itself,  as  seen  by  Peusch.  This  observer  drew  his  conclusions 
from  258  cases  of  atresia,  in  18  of  which  rupture  of  the  Fallopian  tubes 
from  distention  by  menstrual  blood  occurred.  In  one  instance  of  atresia, 
I  saw  an  hematocele  the  size  of  an  infant's  head  result  from  discharge  of 
blood  from  the  tubes  into  the  peritoneal  cavity.  It  is  possible  that  the 
mental  emotion  of  the  patient,  and  her  struggles  during  the  operation,  may 
account  for  the  escape  of  blood  into  the  peritoneum  as  noted  by  Bernutz. 
Hence,  every  effort  should  be  made  to  avoid  these,  by  complete  anaesthesia, 
and  care  should  be  taken  not  to  allow  of  pressure  upon  the  uterus  either 
intentional  or  accidental. 

In  cases  in  which  vaginal  and  uterine  atresia  have  existed  together,  and 
the  uterus  only  is  distended  by  blood,  there  can  be  no  good  reason  urged 
for  completing  the  removal  of  both  atresia}  at  one  sitting.  It  is  far  safer 
to  secure  complete  liberation  of  the  uterine  neck,  and  perviousness  of  the 
vaginal  canal,  unless  delay  be  absolutely  dangerous,  and  then,  after  the 
dangers  arising  from  this  procedure  have  passed  away,  to  perform  the  other 
operation.  Certainly,  combining  the  two  would  not  diminish  the  danger 
of  either,  while  delay  would  not  ordinarily  increase  the  risk  in  any  way, 
since  the  closure  of  the  cervix  is  so  complete  as  entirely  to  exclude  the 
admission  of  air. 

Lefort  has  advised  and  practised  the  creation  of  a  new  vagina  by  elec- 
trolysis. The  following  is  the  description  given  of  the  procedure  by 
Le  Blond  in  his  admirable  treatise  upon  Gynecological  Surgery.1  The 
operation  rests  upon  the  fact  that  a  mild  continuous  current  of  electricity 
passing  through  tissues  by  means  of  a  metallic  pole  destroys  them.  "  M. 
Lefort  employs  for  the  purpose  a  cylinder  of  boxwood,  the  extremity  of 
which  ends  in  a  copper  bulb  connected  with  the  negative  pole  of  a  pile  of 
Morin  elements  in  sulphate  of  copper.  The  circuit  of  the  pile  is  estab- 
lished by  applying  a  metallic  plate  communicating  with  the  positive  pole 
on  the  stomach  with  the  interposition  of  compresses  soaked  in  a  solution 
of  sodium  chloride.  The  apparatus  is  put  in  position  only  at  night.  At 
the  end  of  a  short  time  the  existence  of  a  canal  of  seven  or  eight  centi- 
metres in  depth  is  found  to  exist,  then  when  the  uterine  neck  is  reached 
the  menstrual  flow  occurs  freely."  I  have  no  experience  in  this  method, 
but  Le  Blond  speaks  with  confidence  concerning  it,  and  gives  it  preference 
over  the  surgical  procedures  which  have  been  detailed. 

1  Traite  Elementaire  de  Chirurg.  Gynecol.  Paris,  1878. 


URINARY    FISTULA.  233 


CHAPTER  XV. 

FISTULA  OF  THE  FEMALE  GENITAL  ORGANS. 

Definition — As  a  result  of  certain  traumatic  and  morbid  processes,  the 
continuity  of  the  vaginal  and  uterine  walls  may  be  destroyed  and  commu- 
nication established  with  adjacent  viscera.  To  the  tracts  or  passages  thus 
opened,  the  name  of  fistulas  has  been  given. 

Varieties — These  communications  connect  the  vagina  or  uterus  with 
some  viscus  in  immediate  proximity,  for  the  natural  outlet  of  which  they 
act  vicariously,  or  with  some  neighboring  part,  as  the  peritoneum,  the 
vulva,  or  the  pelvic  areolar  tissue.  Their  varieties  have  received  the 
following  descriptive  appellations  : — 
Urinary  Fistulce. 

Vesico-vaginal  fistula; 
Urethro- vaginal  fistula ; 
Vesico-utero-vaginal  fistula ; 
Vesico-uterine  fistula; 
Uretero-uterine  fistula  ; 
Uretero-vaginal  fistula. 
Fecal  Fistulce. 

Recto-vaginal  fistula ; 
Entero- vaginal  fistula ; 
Recto-labial  fistula. 
Simple  Vaginal  Fistulce. 

Peritoneo- vaginal  fistula; 
Perineo-vaginal  fistula; 
Blind  vaginal  fistula. 

Urinary  Fistulas. 

Urinary  fistula?  may  occur  on  any  part  of  the  anterior  surface  of  the 
genital  canal  intervening  between  the  vulva  and  fundus  uteri.  Fig.  86 
displays  the  points  at  which  they  are  usually  observed. 

Vesico-  Vaginal  Fistula  (2)  is  a  communication  between  the  bladder 
and  vagina,  either  at  the  trigone  or  the  bas-fond,  which  may  involve  only 
enough  tissue  to  admit  a  small  probe,  or  entirely  destroy  the  vesico-vaginal 
wall.     Such  an  opening  may  be  oval,  angular,  elliptical,  or  linear  in  shape, 


234 


FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 


and  its  borders  may  be  thick  or  thin,  soft  or  indurated,  rough  or  smooth, 
pale  or  vascular. 

Urethro-  Vaginal  Fistula  (1)  resembles  that  just  mentioned,  except  in 
the  fact  that  the  destruction  of  tissue  which  has  produced  it  involves  the 
wall  of  the  urethra,  and  not  that  of  the  bladder. 

Fig.  86. 


Varieties  of  urinary  flstulae :  1.  Urethro-vaginal  fistula  ;  2.  Vesico-vaginal  fistula  ;  3.  Vesico- 
uterovaginal fistula;  4.  Vesico-uterine  fistula. 

Vesi co- Uterine  Fistula  (4)  are  those  in  which  there  is  a  direct  commu- 
nication between  the  bladder  and  uterus  above  the  jiointof  vaginal  attach- 
ment. The  vagina  is  consequently  not  involved,  and  the  urine  passing 
into  the  uterus  escapes  at  the  os. 

Vesico-Utero- Vaginal  Fistulce  (3)  are  those  in  the  production  of  which 
a  lesion  occurs  in  both  uterus  and  vagina,  as  is  imperfectly  shown  by  (3). 
At  the  vaginal  junction  there  is  a  perforation  of  the  bladder,  but  this  does 
not  penetrate  to  the  cavity  of  the  uterus.  A  canal  is  created  in  its  wall, 
and  through  this  the  urine  escapes  into  the  vagina.  The  last  two  forms 
of  fistula?  were  first  accurately  described  by  Jobert,  who  made  of  the  last, 
two  varieties,  superficial  and  deep..  In  the  first  a  canal  is  channelled  out 
on  the  vesical  surface  of  the  cervix  uteri  ;  in  the  second,  the  cervix  is  to 
a  greater  or  less  extent  destroyed  by  the  process  of  sloughing,  and  through 
it  the  urine  passes.  In  the  first  form  the  lesion  is  chiefly  vesical  and  ute- 
rine, the  vagina  not  being  much  injured;  in  the  other  it  affects  three 


URINARY    FISTULJE — CAUSES.  235 

organs,  the  bladder,  the  uterus,  and  the  vagina.  All  these  forms  of  fistulas 
may  thus  be  grouped  into  elasses  : — 

1st  Class.  Those  involving  the  urethra. 

2d  Class.  Those  involving  the  base  of  the  bladder. 

3d  Class.  Those  involving  the  uterus. 

4th   Class.  Those  involving  the  ureters. 
In  some  cases,  however,  multiple  fistula?  exist,  and  no  special  classifi- 
cation can  be  made. 

Causes Any  influence  which  is  capable  of  destroying  the  continuity 

of  the  vaginal  walls,  either  by  mechanical,  chemical,  or  vital  action,  would 
of  course  give  rise  to  this  condition.  Those  which  are  found  in  actual 
practice  to  have  proved  most  commonly  efficient,  are  the  following  : — 

1st.  Prolonged  or  very  severe  pressure  ; 

2d.  Direct  injury ; 

3d.  Ulceration  or  abscess. 
Pressure,  which  is  more  frequently  a  cause  than  any  of  the  others 
mentioned,  is  generally  produced  by  the  child's  head  remaining  too  long 
in  the  pelvis  during  labor.  This  is  beyond  all  doubt  the  most  prolific 
source  of  the  accident,  though  it  may  also  attend  a  rapid  labor  in  which 
the  vagina  has  been  pressed  against  some  point  of  the  pelvis  with  great 
violence.  Such  pressure  produces  sloughing  of  the  part  of  the  vagina 
receiving  it,  and  at  that  spot  a  deficiency  of  tissue  in  future  exists,  which 
constitutes  a  fistula.  The  process  of  sloughing  occurs  from  pressure  of 
the  foetal  head,  exactly  as  a  bedsore  takes  place  in  one  who  lies  for  too 
long  a  time  in  the  same  position,  the  sequence  being,  disturbed  and  re- 
tarded circulation,  impaired  nutrition,  and  local  death.  Or  a  puerperal 
vaginitis  may  be  established,  which  runs  a  violent  course,  and  may  end 
in  sloughing  after  several  weeks'  duration. 

An  involuntary  flow  of  urine  usually  announces  the  existence  of  a 
fistula  within  three  or  four  days  after  delivery,  though,  when  it  is  the 
result  of  injury  inflicted  by  instruments  employed  in  delivery,  it  may 
occur  immediately.  On  the  other  hand,  the  separation  of  the  slough, 
which  will  entail  deficiency  of  tissue  and  its  results,  may  not  take  place 
until  much  later,  when  perhaps  all  fears  are  allayed,  and  the  case  is 
regarded  as  progressing  favorably.  Jean  Louis  Petit  records  one  case 
developing  its  symptoms  after  a  month  ;  Jobert  one  in  which  on  the 
twenty-second  day  after  delivery  the  slough  was  found  at  the  mouth  of  the 
vagina  ;  Adler,  of  Iowa,  one  in  which  after  twenty-nine  days  the  slough 
was  only  partially  separated  ;  and  Agnew,  of  Philadelphia,  another,  in 
which  it  separated  on  the  twenty-first  day. 

Other  agencies  which  may  create  fistula?,  but  which  have  been  rarely 
noticed  to  do  so,  are  pessaries,  stones  in  the  bladder,  fecal  accumulation, 
etc. 


236  FISTULiB    OF    THE    FEMALE    GENITAL    ORGANS. 

Direct  injury  may  produce  the  accident  by  contusing  or  lacerating  the 
vaginal  walls,  as  may  occur  during  delivery  by  the  forceps  or  craniotomy. 
That  these  operations  when  carelessly  or  unskilfully  performed  may  pro- 
duce a  fistula,  no  one  will  pretend  to  deny,  but  there  can,  with  the  evi- 
dence now  recorded,  be  no  doubt  that  they  have  often  been  credited  with 
unfortunate  results  which  were  in  reality  due  to  tardiness  in  their  employ- 
ment. Very  often,  where  a  labor  has  been  allowed  to  be  prolonged  in  the 
second  stage  until  the  vitality  of  certain  points  in  the  vagina  has  become 
irremediably  impaired,  and  the  process  of  sloughing  has  been  already  in- 
augurated, subsequent  delivery  by  forceps  or  craniotomy  has  been  regarded 
as  producing  fistula.  Under  such  circumstances  the  real  morbid  agency, 
prolonged  and  violent  pressure,  is  lost  sight  of,  and  the  more  palpable 
agents,  the  instruments  employed,  are  viewed  as  the  source  of  the  acci- 
dent. The  truth  with  reference  to  this  point  should  be  well  understood 
by  every  practitioner,  for  unless  it  be  so,  an  incompetent  person  may 
shield  himself  from  merited  blame  by  casting  censure  upon  a  consulting 
physician  by  whose  efforts  the  lives  of  both  mother  and  child  have  been 
saved,  or  a  skilful  operator  may  suffer  unjustly  in  a  suit  for  malpractice. 

In  a  report  upon  this  subject  by  Mr.  I.  Baker  Brown1  to  the  Obstetrical 
Society  of  London,  in  1863,  the  following  statements  are  made:  "With 
regard  to  the  causes  of  vesico-vaginal  fistula,  of  the  58  cases  admitted 
into  the  London  Surgical  Home,  47  were  over  24  hours  in  labor,  and  39 
were  as  much  as  36  hours  or  more  ;  7  were  two  days  ;  16  were  three  days  ; 
3  were  four  days ;  2  were  five  days ;  2  six  days ;  and  1  seven  days. 

"  In  the  whole  number  of  cases  instruments  were  used  in  29,  exactly 
one-half,  and  in  4  only  of  these  was  the  labor  less  than  twenty-four  hours, 
and  with  seven  exceptions  the  patient  had  been  thirty-six  hours  or  more 
in  labor  before  instruments  were  used. 

"  Of  the  58  cases,  in  24  only  the  injury  happened  at  the  first  labor ;  in 
7  at  the  second  ;  in  5  at  the  third  ;  in  4  at  the  fourth ;  in  6  at  the  fifth ; 
in  2  at  the  sixth ;  in  5  at  the  eighth ;  in  1  at  the  ninth ;  1  at  the  thir- 
teenth ;  1  at  the  fifteenth ;  and  2  not  mentioned." 

"  From  the  foregoing  statistics  it  is  evident  that  the  cause  of  the  lesion 
is  protracted  labor,  and  not  the  use  of  the  instruments  or  deformity  of  the 
pelvis." 

"As  a  necessary  deduction  from  what  has  been  stated,  it  follows  that 
vesico-vaginal  fistula  would  scarcely  if  ever  occur,  if  a  labor  were  not 
allowed  to  become  protracted  ;  and  this  is  a  point  for  the  careful  consider- 
ation of  practitioners  in  midwifery."  The  experience  of  Dr.  Sims2  is 
confirmatory  of  that  of  Mr.  Brown.      Emmet,  whose  authority  in  this 

1  Obstet.  Trans.,  vol.  v.  p.  23. 

*  Gardner's  Notes  to  Scanzoni,  p.  503. 


URINARY    FISTULA — SYMPTOMS.  237 

matter  is  very  high,  gives  the  causes  of  179  cases,1  and  171  of  the  number 
originated  in  childbirth. 

Jt  may  be  said  in  a  general  way  then  that  the  cause  of  urinary  fistula? 
in  the  female  is  parturition,  a  few  exceptions  to  the  rule  occurring ;  that 
protracted  labor  is  very  generally  productive  of  them ;  and  that  the 
prompt  use  of  instruments  is,  as  a  rule,  preventive  of  them. 

It  is  a  curious  fact  that,  when  for  the  relief  of  chronic  cystitis  a  vesico- 
vaginal fistula  is  intentionally  created  by  the  knife,  it  is  difficult  to  keep 
it  open.  In  spite  of  the  occasional  introduction  of  the  sound  for  this 
purpose,  such  openings  obstinately  heal  of  their  own  accord,  so  that  it 
becomes  necessary  to  place  a  species  of  button  or  stud  in  the  opening 
to  prevent  an  issue  which,  under  these  circumstances,  is  undesirable. 
This  case  seems  parallel  with  that  of  perforation  of  the  tympanum,  which, 
being  effected  by  an  instrument,  heals  rapidly ;  while  the  closure  of  an 
opening,  the  result  of  disease,  is  usually  impossible. 

About  thirty  years  ago  Dieffenbach2  recorded  a  case  of  vesico-vaginal 
fistula,  the  cause  of  which  had  been  the  presence  of  a  stone  in  the  bladder, 
complicating  labor;  and  Baker  Brown3  mentions  another  instance  of  this 
kind  in  1861. 

Ulceration  or  Abscess The  vaginal  walls  may  be  eaten  through  by 

cancerous,  syphilitic,  or  phagedenic  ulcers,  or  a  communication  may  be 
established  by  an  abscess  opening  into  the  vagina  and  into  a  neighboring 
viscus  or  part.  In  one  case  I  found,  in  the  autopsy  of  a  woman  who  had 
died  from  a  profuse  diarrhoea,  in  which  the  leces  had  passed  by  the 
vagina,  a  communication  created  by  abscess  between  the  caput  coli  and 
that  canal. 

Cancerous  disease  often  destroys  the  vesico-vaginal  septum,  but  as 
these  fistulas  are  irremediable,  and  attend  upon  a  rapidly  fatal  disorder, 
they  attract  little  attention  in  themselves.  Lastly,  certain  diseases  pro- 
ducing deficiency  of  nutrition,  as,  for  example,  the  continued  fevers,  may 
cause  sloughing  of  the  vaginal  walls  or  phagedenic  ulceration. 

Symptoms — The  prominent  symptoms  and  signs  of  urinary  fistulas 
may  be  grouped  under  three  heads  :  first,  those  furnished  by  a  character- 
istic discharge ;  second,  those  arising  from  the  irritant  action  of  such 
discharge  upon  the  part  over  which  it  flows ;  and,  third,  those  afforded 
by  physical  examination. 

Sometimes  the  escape  of  urine  is  so  excessive  as  to  preclude  the  neces- 
sity of  a  discharge  per  vias  naturales ;  at  others  the  excretion  is  partly 

1  Principles  and  Practice  of  Gynecology.  The  author  gives  in  his  tables  202 
cases,  but  I  subtract  23  which  were  intentionally  produced  for  removal  of  stone 
and  cure  of  cystitis.     Evidently  these  are  not  admissible  in  the  study  of  Etiology. 

2  Med.  Record,  vol.  i.  321.  3  Op.  cit. 


238  FISTULiB    OF    THE    FEMALE    GENITAL    ORGANS. 

evacuated  by  the  natural  and  partly  by  the  vicarious  outlet.  This  symp- 
tom shows  at  times  eccentric  variations.  When  the  fistula  is  seated  in 
the  urethra,  the  bladder  may  be  distended  without  loss,  which  may  take 
place  into  the  vagina  during  micturition.  Sometimes  while  in  the  hori- 
zontal posture  the  escape  will  cease,  the  anterior  vesical  wall  being  pressed 
by  the  intestines  against  the  bas-fond  so  as  to  close  the  opening ;  and  in 
other  cases,  where  the  fistula  is  above  the  orifice  of  the  ureters,  the  How 
will  take  place  while  the  patient  lies,  and  cease  when  she  stands. 

The  passage  of  excrementitious  material  through  a  canal  and  over  a 
tissue  not  intended  by  nature  to  tolerate  it,  produces  inflammatory  action, 
pruritus,  eruptions,  and  excessive  irritability.  In  urinary  fistulae  the 
vulva  and  thighs  are  usually  red,  excoriated,  and  covered  by  a  vesicular 
eruption.  The  vagina  is  sometimes  covered  by  urinary  concretions,  and 
a  highly  offensive  odor  emanates  from  the  patient's  body. 

The  general  health  is  very  likely  in  time  to  give  way,  and  hysteria, 
chlorosis,  and  graver  disorders  often  show  themselves. 

Physical  Signs If  the  fistulous  orifice  be  a  large  one,  even  a  super- 
ficial examination  by  touch,  the  patient  lying  upon  her  back,  will  gene- 
rally serve  to  reveal  the  nature  and  extent  of  the  lesion.  It  is  different, 
however,  with  very  small  fistulae,  which  will  sometimes  elude  the  most 
careful  investigation.  For  their  detection  Sims's  speculum  should  be 
employed,  and  in  many  cases  it  will  be  found  advisable  to  place  the  woman 
in  the  knee-elbow  position,  instead  of  that  on  the  side,  before  its  intro- 
duction, and  to  have  the  buttocks  and  labia  pulled  apart  by  the  hands  of 
assistants.  Even  this  method  is  not  effectual  in  revealing  the  opening  if 
it  be  very  minute.  Under  these  circumstances  the  bladder  should  be 
injected  with  water,  and  its  escape  into  the  vagina  carefully  watched  for. 
Sometimes,  by  this  means,  a  capillary  opening,  just  at.  the  junction  of  the 
vagina  and  cervix,  will  be  detected.  Kiwisch,  Meyer,  Veit,  and  others 
have  used  for  this  purpose  water  colored  with  substances  which  will  im- 
part a  bright  tinge  to  it.  Infusion  of  cochineal,  madder,  or  indigo  may 
be  thus  employed.  The  opening  being  once  detected,  the  probe  and 
finger  will  readily  reveal  the  course,  extent,  and  terminus  of  the  tract. 

Complications The  complications  which  these  fistulae  develop  are 

vaginitis,  vulvitis,  stricture  of  urethra  and  vagina,  and  sometimes  endo- 
metritis and  periuterine  inflammation.  The  most  constant  and  important 
of  these  is  the  formation  of  bands,  which  contract  the  vagina,  and  which 
often  require  severance  before  operative  procedure  can  be  practised. 

Prognosis — Previous  to  the  year  1852,  the  prognosis  of  all  cases  in 
which  the  orifice  acted  as  a  vicarious  outlet,  for  example,  vesico-vaginal, 
recto-vaginal,  and  vesico-utero-vaginal  fistulae,  was  eminently  unfavorable, 


URINARY    FISTULA  —  HISTORY.  2iJ9 

for  they  very  rarely  undergo  spontaneous  recovery,  and  the  means  of  cure 
at  our  command  up  to  that  time  were  uncertain  and  full  of  discouragement. 
In  18G0,  Dr.  Sims1  stated,  "Of  2G1  cases  of  vaginal  fistula  (vesical  and 
rectal)  21 G  have  been  permanently  cured  by  the  silver  wire  suture,  3G 
are  curable,  and  9  incurable.  Every  case  is  curable  when  the  operation 
is  practicable,  provided  there  is  no  constitutional  vice  to  interfere  with 
the  powers  of  union.     Success  is  the  rule,  failure  the  exception." 

The  enlarged  experience  of  the  profession  has  fully  corroborated  these 
assertions,  made  twenty  years  ago,  and  it  may  now  be  accepted  as  a  true 
statement  as  to  the  prognosis  of  all  fistula?  of  the  female  genital  organs 
except  cases  of  vesico-uterine  fistula,  in  which  the  point  of  rupture  is  out 
of  reach  of  surgical  interference. 

History The  history  of  this  subject  dates  back  only  to  the  sixteenth 

century,  when  attention  was  called  to  it,  and  a  plan  of  treatment  proposed 
by  Ambrose  Pare.  Before  the  discovery  of  the  forceps,  the  accident  must 
have  been  one  of  very  frequent  occurrence,  for  then  powerless  labor  was 
not  under  the  control  of  the  obstetrician,  except  by  resort  to  a  set  of  badly 
constructed  instruments  for  craniotomy,  which  in  themselves  presented 
serious  dangers  of  laceration.  The  symptoms  which  mark  its  existence 
are  so  palpable  and  distressing  that  it  does  not  require  a  physician  to 
diagnosticate  it,  and  no  case  of  any  gravity  could  have  escaped  notice. 
And  yet,  curious  to  relate,  there  are  few  diseases  to  which  woman  is  liable, 
which  have  received  so  little  notice  at  the  hands  of  the  ancients.  Even 
pelvic  cellulitis  and  other  affections,  which  have  but  lately  attracted  atten- 
tion from  the  physicians  of  our  day,  are  distinctly  alluded  to  by  the  writers 
of  the  Greek  school ;  but  this  one,  so  annoying,  so  destructive  of  happiness, 
and  so  urgent  in  its  demands  for  relief,  has  received  scarcely  any  mention. 
It  is  true  that  Hippocrates  makes  some  slight  allusion  to  involuntary  dis- 
charge of  urine  following  difficult  labors,  but  his  remarks  upon  the  condi- 
tion are  meagre  and  unimportant. 

I  do  not  claim  to  have  made  a  full  examination  of  the  writings  of  the 
Greeks  and  Romans  with  reference  to  the  subject,  but  base  the  statement 
which  I  have  advanced  chiefly  upon  the  fact  that  the  two  great  compilers 
of  their  periods,  Aetius  and  Paulus  iEgineta,  make  no  mention  of  it.  The 
work  of  Aetius  upon  diseases  of  women  (Tetrabiblos  IV.)  is  made  up  of 
quotations  from  Soranus,  Aspasia,  Galen,  Philumenus,  Archigenes,  Leo- 
nidas,  Rufus,  Philagrius,  Asclepiades,  in  fact  of  all  worthy  of  note,  whose 
writings  were  stored  in  the  Alexandrian  Library,  which  was  the  seat  of 
his  labors.  By  none  of  these  is  mention  made  of  the  affection.  The 
works  of  Paul  of  iEgina,  enriched  as  they  have  been  by  the  copious  notes 
of  Dr.  Adams,  their  translator,  are  equally  silent ;  and  the  researches  of 

1  Gardner's  Notes  to  Scanzoni,  p.  515. 


240  FISTULA    OP    THE    FEMALE    GENITAL    ORGANS. 

those  who  have  examined  the  writings  of  the  Arabians  record  no  discovery 
of  any  description  of  it  at  their  hands.  At  any  rate,  it  is  quite  certain 
that  no  contributions  to  the  treatment  of  the  difficulty  were  made  by  the 
writers  of  the  Greek,  Roman,  or  Arabian  schools. 

Beginning  at  the  seventeenth  century,  I  will  allude  only  to  those  who 
have  made  some  advance  in  treatment,  and  not  endeavor  to  record  the 
names  of  all  who  have  reported  cures,  or  advised  procedures  which  have 
not  been  of  subsequent  utility. 

Before  proceeding  with  the  historical  sketch  which  ensues,  I  would  draw 
the  attention  of  the  reader  to  two  interesting  facts  which  it  will  demon- 
strate. It  will  be  seen  that  for  centuries  steady,  persevering,  and  syste- 
matic efforts  have  been  made  to  render  this  revolting  malady  curable,  and 
that,  as  has  often  been  the  case  in  other  great  discoveries,  the  minds  of 
several  investigators  pursued  the  same  course  until  at  last  success  was 
reached.  After  a  discovery  has  been  made  it  is  always  easy  to  point  out 
the  elements  upon  which  it  rests  for  its  success,  and  even  to  follow  the 
process  of  reasoning  by  which  each  in  turn  was  supplied.  There  can  be 
no  doubt  that  the  three  elements  necessary  for  successful  treatment  of  the 
lesion  which  we  are  considering,  were — 

1st.  A  means  for  exposing  the  fistula  to  view  and  manipulation  ; 

2d.  A  suture  which  would  remain  in  place  without  causing  inflamma- 
tion ; 

3d.  A  means  of  disposing  of  the  urine  during  the  process  of  cure. 

From  the  time  that  Pare  suggested  a  plan  of  treatment,  it  will  be  no- 
ticed that  surgeons  brought  these  three  means  of  cure  to  their  aid.  But 
they  employed  them  separately,  some  using  one  of  them,  some  another, 
and  others  still  combining  two.  It  was  not,  however,  till  the  time  of  Gos- 
set,  in  1834,  that  the  three  were  combined  by  the  same  operator. 

In  1570,  Ambrose  Pare  proposed  the  closure  of  vesico- vaginal  fistulaeby 
a  retinaculum.  In  1GG0,  Roonhuysen,  of  Amsterdam,  used  a  speculum, 
through  which  he  pared  the  edges  of  fistula?  and  united  them  by  a  needle. 
In  1720,  Voelter,  of  Wurtemberg,  advised  a  needle,  needle-holder,  suture 
by  silk  or  hemp,  and  a  catheter.  In  1792,  Fatio,  of  Basle,  operated  by 
twisted  suture,  placing  his  patients  in  the  lithotomy  position.  In  1804, 
Dessault  used  a  vaginal  plug  and  catheter  in  the  bladder.  In  1812, 
Naegele,  of  Wurtemberg,  scarified  the  edges  by  scissors,  used  needles  to 
approximate  them,  and  employed  the  interrupted  suture.  In  1817,  Schre- 
ger,  of  Germany,  placed  the  patient  on  the  abdomen,  scarified  the  edges, 
and  used  interrupted  suture.  In  182"),  Lallemand,  of  France,  applied 
nitrate  of  silver  to  the  edges  of  the  fistula,  and  approximated  them  by  a 
"  sonde  erigne"  passed  through  the  bladder,  and,  of  fifteen  cases,  cured 
four.  In  1829,  Roux,  of  France,  tried  twisted  suture  with  metallic  bars 
and  ordinary  thread.  In  1834,  Gosset,  of  London,  combined  the  knee- 
elbow  position,   levator   perinei  .speculum,  metallic  sutures,  and  catheter 


URINARY    FISTULA HISTORY.  241 

permanently  kept  in  the  bladder.  In  1836,  Beaumont1  employed  the 
(milled  or  clamp  suture.  In  1837,  Jobert  de  Lamballe  resorted  to  auto- 
plasty,  transplanting  a  piece  from  the  labia,  buttocks,  or  thighs.  In  1838, 
Wutzer,  of  Bonn,  placed  his  patients  on  the  abdomen,  pared  the  edges  of 
the  fistula,  and  approximated  them  by  insect  needles  and  figure-of-8  suture. 
To  expose  the  fistula  the  perineum  was  held  up  by  a  hook  and  the  labia 
drawn  aside  by  assistants.  In  1839  and  1840,  Hay  ward,  of  Boston,  U.  S., 
reported  three  cases  cured  by  vivifying  the  edges  and  closing  with  silk 
suture.  This  surgeon  introduced  a  notable  improvement,  and  aided  in 
the  final  success  by  vivifying  not  only  the  borders  of  the  fistula  but  the 
neighboring  vaginal  surfaces.  In  1844,  Chelius2  placed  his  patients  in  the 
knee-elbow  position.  In  184G,  Metzler,3  of  Prague,  employed  the  levator 
perinei  speculum,  perforated  balls  the  size  of  shot,  the  knee-elbow  position, 
gilded  needles,  and  a  permanent  catheter.  In  1847,  Mettauer,  of  Vir- 
ginia, employed  the  catheter  and  leaden  sutures  with  such  success  that  he 
was  led  to  make  the  following  statement :  "  I  am  decidedly  of  the  opinion 
that  every  case  of  vesico-vaginal  fistula  can  be  cured,  and  my  success  jus- 
tifies the  opinion."  In  1852,  Jobert  de  Lamballe  adopted  his  method, 
styled  "  reunion  autoplastique  par  glissement,"  which  consisted  in  giving 
sufficient  vaginal  tissue  for  union,  by  cutting  transversely  through  the 
vagina,  at  its  junction  with  the  uterus,  in  a  line  with  the  fistula.  In  1852, 
Marion  Sims,4  of  the  United  States,  combined  the  three  essentials  for  suc- 
cess; the  speculum,  the  suture,  and  the  catheter,  and  placed  the  operation 
at  the  disposal  of  the  profession. 

The  discoveries  to  which  he  laid  special  claim  were  these : — 

1st.  A  method  by  which  the  vagina  could  be  distended  and  explored  ; 

2d.  A  suture  not  liable  to  excite  inflammation  or  ulceration ; 

3d.  A  method  of  keeping  the  bladder  empty  during  the  process  of  cure. 

Entering  the  field  almost  as  early  as  Sims,  Simon,  of  Germany,  greatly 
aided  in  systematizing  the  operation,  and  has  been  second  to  no  one  else 
in  improving  it. 

From  a  study  of  the  literature  of  this  subject  it  is  made  as  evident  as 
written  testimony  can  make  any  history  of  the  past,  that  not  only  did 
several  investigators  combine  two  of  these  elements  of  success  in  their 
operations,  but  that  two,  Gosset,  in  England,  and  twelve  years  afterwards 
Metzler,  in  Germany,  absolutely  combined  all  three.  It  is  also  made 
equally  evident  that  they  either  failed  to  recognize  the  importance  of  what 
they  had  attained,  or  did  not  impress  its  value  upon  others  so  that 
humanity  could  profit  by  it.  Dr.  Gosset's  procedure  is  thus  described  in 
his  own  words  in  the  first  volume  of  the  London  Lancet,  page  346. 

"  Having  placed  the  patient  resting  upon  her  knees  and  elbows,  upon 

1  Med.  Gaz.,  Dec.  3d,  1836,  p.  355.  «  Agnew,  op.  cit.,  p.  15. 

3  Schuppert  on  Ves.-Vag.  Fistula,  p.  41.  «  Ainer.  Journ.  Med.  Sei.,  1852. 

16 


242  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

a  firm  (able  of  convenient  height  covered  with  a  folded  blanket,  the  ex- 
ternal parts  were  separated  as  much  as  possible  by  a  couple  of  assistants, 
so  as  to  bring  the  fistula,  which  was  immediately  above  the  neck  of  the 
bladder,  into  view.  I  seized  with  a  hook  the  upper  part  of  the  thickened 
edge  of  the  bladder  which  surrounded  the  opening,  and  proceeded  with  a 
spear-shaped  knife  to  remove  an  elliptical  portion,  which  included  the 
whole  of  the  callous  lip  surrounding  the  fistula,  the  long  angle  of  the 
ellipsis  being  transversely.  This  was  readily  effected ;  but,  in  conse- 
quence of  the  very  contracted  state  of  the  parts,  the  next  steps  of  the 
operation  were  with  difficulty  executed  ;  and  I  should  not  have  succeeded 
in  passing  the  sutures,  had  I  not  used  needles  very  much  curved,  and  a 
needle-holder  which  I  could  disengage  at  pleasure,  the  needles  being  with- 
drawn with  a  pair  of  dissecting  forceps  after  the  holder  was  removed.  In 
this  way  three  sutures  were  passed ;  and  afterwards,  by  twisting  the  wire, 
the  incised  edges  were  brought  into  contact  and  retained  in  complete 
apposition  until  they  had  firmly  united.  One  of  the  sutures  was  removed 
at  the  end  of  the  ninth  day,  the  second  at  the  end  of  the  twelfth  day,  and 
the  third  was  allowed  to  remain  until  three  weeks  had  elapsed.  After 
the  operation  the  patient  was  put  to  bed  and  desired  to  lie  on  her  face,  an 
elastic  gum  catheter,  having  a  bladder  secured  to  its  extremity  for  the 
reception  of  the  urine,  having  been  introduced  and  retained  by  means  of 
tapes.  She  had  not  the  slightest  discharge  of  urine  through  the  vagina 
after  the  operation,  which  completely  succeeded  in  restoring  the  healthy 
functions  of  the  part.  The  advantages  of  the  gilt  wire  suture  are  these: 
it  excites  but  little  irritation,  and  does  not  appear  to  induce  ulceration 
with  the  same  rapidity  as  silk  or  any  other  material  with  which  I  am 
acquainted;  indeed,  it  produces  scarcely  any  such  effect,  except  when  the 
parts  brought  together  are  much  stretched.  You  can,  therefore,  keep  the 
edges  of  a  wound  in  close  contact  for  an  indefinite  length  of  time,  by 
which  the  chances  of  union  are  greatly  increased.  I  have  used  it  now  in 
very  many  operations,  as  after  extirpation  of  the  breasts,  tumors  of  various 
kinds,  and  for  bringing  the  lips  together  after  the  removal  of  a  cancerous 
growth,  in  all  of  which  cases  it  answered  extremely  well." 

The  method  of  Metzler  was  published  in  the  Prague  Viertel  Jahresschrift 
for  1846,  under  the  title  of  "Pathology  and  Treatment  of  Urinary  and 
Vesico- Vaginal  Fistulas,  with  a  method  of  treatment  easily  executed  and 
completely  successful."  I  transcribe  his  article  from  the  brochure  of  Dr. 
Schuppert  already  alluded  to. 

"  To  perform  the  operation  successfully,  it  is  of  much  importance  to 
have — 1st,  a  speculum,  serving  as  a  dilator  of  the  vagina.  Such  an  in- 
strument consists  of  a  grooved  conical  blade,  five  and  a  half  inches  long, 
three  inches  wide  at  the  anterior  part,  one-half  an  inch  wide  at  the 
posterior.  The  end  of  the  speculum  is  bent  under  at  a  right  angle,  and 
protected  with  wood  for  the  handle.     The  instrument  is  best  when  made 


URINARY    FISTULA  —  HISTORY.  24'5 

of  silver,  and  polished  to  reflect  the  light  on  the  parts  to  he  operated  upon. 
2d,  an  apparatus  consisting  of  perforated  clamps,  gilded  needles,  and  an 
instrument  called  '  Rosenkranzwerkzeug,'  consisting  of  perforated  halls  of 
the  size  of  large  shot,  hy  which  the  clamps  are  held  in  contact.  After 
the  patient  is  placed  on  her  knees  and  elbows,  the  dilator  is  introduced 
into  the  vagina  and  given  to  an  assistant,  who  in  holding  it  presses  it 
against  the  rectum.  The  edges  of  the  fistula  are  then  pared  off,  which 
may  he  accomplished  with  curved  scissors.  One  line  and  a  half  from  the 
mucous  membrane  of  the  vagina  and  half  a  line  from  the  edge  of  the 
bladder  have  to  be  cut  off;  the  needles  are  then  applied,  and  the  wound 
held  in  coaptation  by  the  clamps;  a  female  catheter  is  introduced  into  the 
bladder  by  the  urethra,  and  the  catheter  fastened  by  a  T  bandage." 

From  what  has  been  said  thus  far  it  would  appear  that  Dr.  Sims  was 
forestalled  in  all  the  details  of  the  discovery  by  which  he  has  rendered 
vaginal  fistula?  curable.  To  a  certain  extent  this  is  unquestionably  true, 
but  only  as  regards  the  theory  of  the  matter.  Before  his  publications  the 
unfortunate  women,  whose  lives  were  rendered  miserable  by  fistula; 
through  the  vaginal  wall,  were  virtually  almost  as  hopelessly  affected  as 
they  were  before  Gosset  and  Metzler  appeared  in  the  field. 

Yelpeau,1  in  1839,  thus  speaks  of  cure  of  these  fistuke:  "To  abrade  the 
borders  of  an  opening,  when  we  do  not  know  where  to  grasp  them;  to 
shut  it  up  by  means  of  needles  or  thread,  when  we  have  no  point  appa- 
rently to  secure  them;  to  act  upon  a  movable  partition  placed  between 
two  cavities,  hidden  from  our  sight,  and  upon  which  we  can  scarcely  find 
any  purchase,  seems  to  be  calculated  to  have  no  other  result  than  to  cause 
unnecessary  suffering  to  the  patient."  Vidal  de  Cassis2  says:  "I  do  not 
believe  that  there  exists  in  the  science  of  surgery  a  well-authenticated, 
complete  cure  of  vesico- vaginal  fistula."  Malgaigne,3  in  1854,  says: 
"But  the  truly  rational  method,  that  which  at  present  offers  the  greatest 
facility  and  efficacy,  and  the  only  one  which  should  be  applied  in  all  cases 
of  fistula  of  large  size,  is  the  suture  by  the  procedure  of  Jobert." 

"Wutzer  reported  the  following  as  the  statistics  which  he  had  collected:* 
"  20  cases  of  vesico- vaginal  fistula  were  subjected  to  48  operations — among 
which  were  elytroplastie,  episioraphie,  cauterization,  sutures,  interrupted 
or  twisted,  and  both — and  only  two  cured!" 

This  was  the  real  state  of  science  with  reference  to  this  opprobrium 
cliirurgice  when  Marion  Sims,  by  combining  and  utilizing  the  three  essen- 
tials for  success,  gained  it,  and  rendered  the  operation  practicable  for  all 
surgeons.  It  must  not  be  supposed  that  he  availed  himself  of  the  results 
obtained  by  his  predecessors.  All  that  he  attained  was  arrived  at  by  hard 
and  original  labor.      Indeed,  no  one   can   read   his  address  upon  "  Silver 

1  Operative  Surgery.  2  Patliologie  Externe. 

3  Manuel  de  Med.  OpSrat.  4  Med.  Record,  vol.  i.  p.  322. 


244  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

Sutures  in  Surgery,"  delivered  before  the  New  York  Academy  of  Medi- 
cine, in  1857,  without  being  struck  by  his  want  of  familiarity  with  the 
antecedent  literature  of  the  subject  of  his  discourse. 

I  would  not  be  understood  as  claiming  for  America  in  this  matter  more 
than  she  really  deserves — the  establishment  of  the  method  of  cure  upon  a 
firm  and  certain  basis.  To  claim  more  than  this  would  be  to  ignore  the 
plain  teaching  of  history.  To  France  belongs  the  inception ;  to  England 
the  glory  of  having  absolutely  made  the  discovery,  although  she  did  not 
appreciate  the  fact ;  to  Germany,  next  to  America,  the  credit  of  having 
specially  advanced  and  perfected  reliable  operative  procedures.  In  that 
country  to-day,  by  the  method  of  Simon,  success  even  in  the  gravest  cases 
has  become  the  rule  and  failure  the  rare  exception. 

Since  the  first  publication  of  Sims's  method,  numerous  modifications  of 
it  have  been  put  into  practice  both  in  this  country  and  Europe,  and  Dr. 
Sims  himself  has  altered  his  plan  of  operating  very  much.  The  principle 
which  he  demonstrated  is,  however,  the  same,  and  the  modifications  of 
the  operation  all  act  in  developing  it. 

In  this  country,  the  operation  is  commonly  performed,  not  by  specialists 
alone,  but  by  practitioners  in  every  walk  of  the  profession,  and,  thanks 
to  the  extreme  simplicity  of  Sims's  procedure,  it  is  no  longer  looked  upon 
as  a  difficult  undertaking,  requiring  special  skill  and  experience.  It  is 
at  the  present  day  certainly  very  difficult  to  appreciate  the  statement  of  a 
physician1  of  Ireland,  that  "  he  unfortunately  had  the  opportunity  of  seeing 
a  great  number  of  fistulas,  and  a  great  number  of  operations,  and  his 
experience  had  been  that  the  vast  majority  of  them  proved  unsuccessful." 

Means  for  Obtaining  a  Natural  Cure. — Within  a  few  days  after  de- 
livery the  obstetrician  is  generally  made  aware  of  the  existence  of  vesico- 
vaginal fistula  by  a  steady  and  involuntary  dripping  of  urine.  As  soon 
as  this  is  evident  a  Sims's  stationary  catheter  should  be  placed  in  the 
bladder,  the  vagina  frequently  syringed  out  with  warm  water  to  lessen 
inflammatory  action,  and  the  patient  kept  in  the  abdominal  decubitus,  in 
order  that  a  repair  of  the  injury  may  be  accomplished  by  the  efforts  of 
nature.  This  is  all  that  can  be  done  at  this  time,  for  it  is  too  early  to 
resort  to  suture,  and  the  lochial  discharge  would  be  interfered  with  by  a 
tampon  intended  to  aid  in  the  cure.  The  operation  by  suture  should  not 
be  undertaken  before  the  immediate  results  of  parturition  have  passed  off' 
and  the  fistula  has  assumed  a  permanent  size  and  character. 

1   Remarks  by  Dr.  Cronyn   before  the  Surgical   Society  of   Ireland,  March   If), 
1  -  72. 


URINARY    FISTULJE  —  TREATMENT.  245 

Treatment. 

The  methods  at  our  command  for  curing,  or,  where  cure  is  impossible, 
obviating  the  inconveniences  due  to  fistula;  of  the  female  urinary  apparatus, 
are — 

1st.   Cauterization  ; 

2d.   Suture  ; 

3d.   Elytroplasty ; 

4th.  Occlusion  of  the  vagina  or  uterus. 

Cauterization. 

This  once  favorite  method  of  treating  all  varieties  of  these  fistula}  has 
now  very  deservedly  fallen  into  disuse  under  the  influence  of  improved 
methods  by  suture.  Malgaigne  probably  gives  this  means  its  proper  place 
when  he  declares  that  it  should  be  employed  only  in  those  cases  where 
the  fistula  is  scarcely  perceptible.  Even  in  such  cases  Sims's  operation 
is  far  preferable,  and  cauterization  should  be  employed  only  where  some 
special  circumstance,  such  as  want  of  skill  or  of  the  proper  instruments, 
forces  the  operator  to  resort  to  it.  The  performance  of  it  is  very  simple. 
Sims's  speculum  being  passed  so  as  to  expose  the  fistulous  spot,  its  borders 
should  be  thoroughly  touched  with  a  pointed  stick  of  nitrate  of  silver  or 
the  actual  cautery.  This  should  not  be  repeated  before  the  slough  created 
has  separated,  and  an  opportunity  been  allowed  for  granulation  to  fill  up 
the  opening. 

To  check  the  flow  of  urine  through  the  fistulous  orifice  and  support  the 
vaginal  and  vesical  walls  during  the  process  of  granulation,  a  small  tampon 
of  cotton,  a  Gariel's  air  pessary,  or  a  glass  vaginal  plug  should  be  kept 
in  the  vagina,  and,  to  prevent  distention  of  the  bladder,  a  sigmoid  catheter 
should  be  permanently  retained. 

Suture. 

Preparation  of  the  Patient. — No  operation  in  surgery  more  urgently 
demands  a  good  constitutional  condition,  as  an  element  of  success,  than 
this.  Should  the  patient's  health  not  be  good,  and  her  blood-state  be 
abnormal,  a  visit  to  the  country,  exercise,  and  fresh  air,  with  vegetable 
and  mineral  tonics,  will  do  a  great  deal  towards  avoidance  of  failure. 
At  the  same  time  the  vagina  should  be  regularly  syringed  with  warm 
water  to  overcome  local  inflammation,  and  insure  cleanliness.  Should 
the  disorder  which  caused  the  destruction  of  the  vaginal  wall  have  pro- 
duced as  a  complication  cicatricial  bands  in  the  canal,  these  should  be 
cut,  from  time  to  time,  and  allowed  to  heal  over  a  glass  vaginal  plug,  and 
if  contraction  have  taken  place  in  the  urethra,  it  should  be  overcome  by 
bougies.  Before  the  time  of  the  operation  the  bowels  should  be  thoroughly 
evacuated  by  a  cathartic,  and  on  the  day  of  its  performance  very  little 


246  FISTULA    OP    THE    FEMALE    GENITAL    ORGANS. 

food  should  be  taken,  for  fear  that  the  long-continued  use  of  an  anaesthetic 
might  produce  vomiting,  which  would  tear  out  the  sutures. 

Situs's  Operation This  operation  may  be  divided  into  three  parts: — 

1st.   Paring  the  edges  of  the  fistula ; 

2d.  Passing  sutures  through  them  ; 

3d.  Approximating  them  and  securing  the  sutures. 
The  patient,  being  placed  upon  a  table  two  and  a  half  by  four  feet, 
which  is  covered  by  folded  blankets,  is  brought  under  the  influence  of  an 
anaesthetic,  and  placed  in  the  following  position.  She  is  made  to  lie  on 
the  left  side,  with  the  thighs  bent  at  about  right  angles  Avith  the  pelvis, 
the  right  a  little  more  flexed  than  the  left.  The  left  arm  is  placed  behind 
her  back,  and  the  chest  brought  flat  down  upon  the  table  so  that  the 
sternum  may  touch  it.  The  assistant  who  is  to  hold  the  speculum,  which 
is  then  introduced,  does  so  with  the  right  hand,  while  with  the  left  he 
elevates  the  right  side  of  the  nates.  The  table  should  be  so  arranged  that 
a  bright  and  steady  light  may  fall  into  the  vagina,  which  being  then  fully 
distended,  will  be  seen  throughout  its  extent,  except  where  it  is  obscured 
by  the  speculum. 

The  operator,  having  near  him  all  the  instruments,  etc.,  which  he  will 
require,  places  his  assistants  thus:  one  holds  the  speculum,  another  ad- 
ministers the  anaesthetic,  and  a  third  stands  ready  at  his  right  hand  to 
remove  the  blood  accumulating  in  the  vagina,  by  means  of  sponges,  in  the 
sponge-holders,  Fig.  91,  which  are  rapidly  washed  in  a  basin  of  water  that 
stands  by  his  side,  to  be  used  again.  A  fourth  assistant,  if  attainable, 
may  be  well  employed  in  handing  the  instruments  as  they  are  required. 
All  being  ready,  he  proceeds  with  the  first  step  of  the  operation. 

Paring  of  the  Edges  of  the  Fistula The   edge  of  the  fistula,  at  the 

point  which  is  deemed  most  difficult  of  access  and  manipulation,  is  caught 
by  the  tenaculum,  or  with  what  1  much  prefer,  the  tooth  forceps,  shown 


Q 


Fig.  87. 


3TTJ  &FI£YNDERS. 

Curved  scissors. 
Fig.  88. 

Bistoury  for  paring  edges  of  fistula. 


in  Fig.  />f),  and  held  up.     Then  with  a  pair  of  long-handled  scissors,  Fig. 
87,  or  a  knife,  Fig.  88,  a  strip  is  cut,  extending  from  the  mucous  mem- 


URINARY    FISTULiE  —  TREATMENT. 


247 


brane  of  the  bladder  to  that  of  the  vagina,  care  being  taken  not  to  wound 
the  former. 

Fig.  89. 


Fig.  90. 


Showing  bevelling  of  edges,  a, 
vesical  border;  b,  vaginal  border; 
c  c,  incision. 


Fig.  91. 


Sims's  sponge-holder  with  handle 
nine  inches  long. 


Paring  the  edges.     (Wieland  and  Dubrisay.) 

Another  portion  of  the  edge  is  then  seized,  and  removed  like  the  first. 
The  wound  thus  left  should  be  one  bevelled  from  the  vesical  surface  out- 


248  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

wards,  and  great  care  should  be  observed  to  remove  the  entire  border,  for 
upon  this  success  depends. 

It  is  of  great  moment  that  sufficient  tissue  should  be  removed,  and  that 
the  amount  taken  on  the  vaginal  surface  should' be  greater  than  that  near 
the  vesical.  Prof.  Simpson1  makes  this  point  very  clear  by  the  following 
language:  "Enter  the  point  of  your  knife  into  the  vaginal  mucous  mem- 
brane at  some  distance  from  the  fistula ;  then  transfix  with  your  knife  the 
edge  of  the  fistula  to  the  extent  you  intend  to  remove  it,  and  bringing  it 
out  at  the  vesical  border,  carry  it  right  and  left  fairly  round  the  opening, 
so  as,  if  possible,  to  bring  out  a  complete  circle  of  tissue." 

The  abraded  surface,  from  the  edge  of  the  fistula  to  the  point  of  vaginal 
section,  should  measure  at  least  four  lines,  one-third  of  an  inch,  while 
above,  it  should  just  touch  the  vesical  border,  not  invading  its  mucous 
membrane.  This  is  made  evident  by  Fig.  90.  During  this  part  of  the 
operation  the  sponges,  held  in  long-handled  sponge-holders,  will  have  to 
be  freely  resorted  to,  but  the  bleeding  generally  soon  ceases,  and  the 
operator  may  proceed  to  the  second  step. 

Passing  the  Sutures. — The  sutures  are  passed  by  means  of  slightly 
curved  needles  held  in  a  pair  of  strong  forceps,  Fig.  92,  made  for  the  pur- 
pose. In  some  cases  the  metallic  thread,  made  of  annealed  silver,  which 
is  employed,  may  be  passed  at  once,  but  usually  silk  threads  are  first 
passed,  and  the  silver  sutures  are  attached  and  drawn  through.  Dr.  E. 
Cutter  recommends  a  very  ingenious  method  for  avoiding  the  necessity  of 
threading  the  needle,  and  thus  having  a  piece  of  silver  wire  folded  over  so 
as  to  interfere  with  its  passage  through  the  tissues.  He  welds  the  wire 
firmly  to  the  needle  so  that  no  obstruction  exists  at  the  point  of  union.  A 
number  thus  prepared  are  in  readiness  for  each  operation. 

The  needles  which  we  employ  in  the  Woman's  Hospital  are  about 
three-quarters  of  an  inch  long,  round,  slightly  curved,  and  without  cutting 
edges  anywhere.  Dr.  John  T.  Hodgen,  of  St.  Louis,  has  invented  a 
needle  which  serves  an  excellent  purpose.  It  is  a  very  small,  straight, 
short  needle,  with  a  point  like  that  of  a  trocar.  This  passes  readily 
through  the  tissues,  and  to  it  is  attached  a  delicate  silk  thread  which  car- 
ries the  silver  wire,  the  bent  end  of  which  is  rubbed  down  very  small  by 
sand-paper.  The  needle,  held  in  the  grasp  of  the  needle-holder,  should 
be  passed  at  the  angle  of  the  wound  which  is  most  dilficult  of  access,  half 
an  inch  from  the  edge  of  the  incision,  and  brought  out  at  the  vesical 
surface,  but  not  involving  its  mucous  lining.  Fig.  93  represents  the  point 
of  entrance  and  exit  of  the  needle. 

The  point  of  the  needle  having  passed  out,  it  is  engaged  by  the  small, 
blunt   hook   Fig.  98,  until   it   can   be  seized  and  drawn    through  by  the 

1  Diseases  of  Women. 


URINARY    FISTUIwE — TREATMENT. 


240 


needle  forceps.     Then  it  is  plunged  into  the  other  lip  and  drawn  out  half 
an  inch  from  the  edge  of  the  incision.     The  ends  of  the  silk  suture  are 


& 


Xeedles  held  in  forceps. 


Course  of  the  needle,  a,  vesiral  border  ;  b,  vagi- 
nal border  ;  c,  point  of  entrance  of  needle  ;  d,  point 
of  exit  of  needle. 


Fir.  94. 


Passing  the  needle.     (Wieland  and  Duhrisay.) 


then  given  into  the  charge  of  the  assistant  holding  the  speculum,  and 
another  is  passed  in  the  same  way  at  the  distance  of  one-sixth  of  an  inch 
from  the  first.  In  this  way  a  sufficient  number  are  passed  to  close  the 
fistula,  Fig.  95. 

During  this  procedure  the  edge  of  the  fistula  is  to  be  fixed  by  the 
tenaculum,  and  should  firm,  opposing  force  be  needed  to  make  the  needles 
pass,  it  may  be  given  by  that  instrument. 

When  the  needle  is  seized  by  the  forceps  and  pulled  so  as  to  make  the 
thread  follow  it,  some  opposing  force  is  needed,  or  the  thread  might  cut 
through  the  tissues.  This  force  is  offered  in  the  species  of  fork  repre- 
sented in  Fig,  97,  which  is  put  as  a  fulcrum  under  the  thread  at  its  point 
of  exit,  and  made  to  sustain  and  draw  it  through. 

A  bit  of  silver  wire  about  twelve  inches  long  is  attached,  by  bending 


250 


FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 


its  extremity,  to  the  first  silk  suture,  and  by  the  use  of  the  fork  just  men- 
tioned, the  silk  thread  is  drawn  through  so  as  to  make  the  wire  replace  it. 


Figs.  96,  97,  98. 


1 


i 


\\ 


Twisting  the  sutures. 


Fulcrum  for  supporting  wire  while  it  is  twisted. 
Fork  with  hlunt  points  to  aid  the  passage  of  sutures. 
Hook  for  engaging  needle. 


The  silk  is  then  cut  off,  the  silver  suture  put  aside,  and  the  operator  pro- 
ceeds to  replace  each  silk  thread  in  the  same  way.  This  being  accom- 
plished, the  instruments  are  then  changed  in  order  to  effect  the  twisting 
of  the  sutures. 

The  ends  of  the  silver  sutures  being  drawn  together  by  the  lingers,  and 
the  edges  of  the  wound  carefully  approximated,  each  thread  is  slightly 
twisted  so  as  to  keep  the  whole  in  apposition.  Then  the  ends  of  the  first 
suture  are  seized  in  the  bite  of  the  forceps,  Fig.  95,  slipped  into  the  ful- 
crum, Fig.  9G,  and  torsion  is  made  so  as  to  close  the  wound  completely 
at  this  point.  In  this  way  the  sutures  are  twisted  one  after  the  other, 
care  being  taken  not  to  carry  the  torsion  so  far  as  to  strangulate  the  tis- 
sues engaged  in  the  constricting  loop.  Each  suture  is  then  clipped  by  a 
pair  of  scissors,  about  half  an  inch  from  the  edge  of  the  fistula,  and  by 
means  of  forceps  pressed  flat  against  the  vaginal  wall  so  as  not  to  wound 
the  opposite  surface. 

The  bladder  should  then  be  syringed  out  to  remove  all  blood  which 
may  have  accumulated  there  ;  for,  if  a  large  clot  should  be  retained  in 
this  viscus,  it  may  cause  severe  vesical  tenesmus,  and  smaller  ones  may 
block  up  the  mouth  of  the  catheter,  which  is  to  be  kept  in  place  perma- 
nently, and  call  for  its  repeated  removal. 


URINARY    FISTULA TREATMENT. 


251 


The  patient  is  then  placed  in  bed  by  the  assistants,  an  opiate  is  admin- 
istered, and  a  Sims's  sigmoid  catheter  is  passed   into  the  bladder  and  lei't 


Fir..  99. 


\'    2' 


3     4 


K  K  K  K 


Sutures  twisted.     (Wieland  and  Dubrisay.) 

there.  The  mouth  of  this  instrument  projects  beyond  the  vulva,  so  that 
under  it  a  small  china  dish  may  be  placed,  which  will  receive  the  urine 
as  it  passes  through. 


Fig.  100. 


Fig.  101. 


Sims's  catheter,  old  stvle. 


Sims's  catheter,  new  style. 


Dr.  Sims1  has  recently  modified  his  catheter  as  represented  in  Fig. 
101.     To  this  a  rubber  tube  is  attached  which  acts  as  a  siphon. 

The  nurse  should  examine  the  catheter  every  two  or  three  hours  to  be 
certain  of  its  perviousness,  and  to  remove  the  urine  which  collects  in  the 
receptacle  placed  under  it. 

Once  in  every  twenty-four  hours  the  vagina  should  be  syringed  out  with 
tepid  water,  or  with  this  and  white  castile  soap,  or  any  similar  detergent ; 
but  the  bladder  requires  no  further  washing  than  that  mentioned,  except 
in  cases  of  vesical  tenesmus.  The  bowels  should  be  kept  constipated  by 
opium.  The  diet  should  be  governed  by  the  same  rules  which  guide  us 
in  the  management  of  patients  under  other  surgical  operations.  It  should 
be  nutritious  and  unstimulating. 

In  from  eight  to  fourteen  days  the  sutures  should  be  removed.  Dr. 
Sims  declares  that,  "  it  is  unnecessary  to  allow  the  wires  to  remain  longer 
than  the  eighth  day;"  but  others,  calculating  upon  the  innocuousness  of 
metallic  substances  in  the  tissues,  have  left  them  longer.  In  two  of  Dr. 
Schuppert's  cases  a  leaking  was  detected  when  the  bladder  was  injected 
on  the  sixth  and  seventh  days,  which  had  disappeared  entirely  on  the 
twelfth,  when  the  sutures  were  removed  and  the  cure  was  found  complete. 

To  accomplish  the  removal  of  the  sutures,  the  twisted  end  of  one  of 
them  should  he  seized  by  a  pair  of  forceps  and  drawn  upon  gently  until 


1   Le  Blond,  op.  cit.  p.  415. 


252  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

the  edge  of  the  loop  emerges  from  the  tissues  in  which  it  has  been  em- 
bedded. Then  the  blade  of  a  pair  of  scissors  should  be  inserted  into  the 
loop  and  one  side  cut,  after  which  a  little  traction  will  remove  the  suture. 

An  examination  may  then,  with  great  caution,  be  instituted  to  ascertain 
whether  success  or  failure  has  attended  the  operation.  A  visual  examina- 
tion will  generally  determine  this.  Should  there  be  any  doubt,  the  bladder 
may  be  filled  very  cautiously  with  tepid  water  to  settle  the  question  as  to 
the  entire  closure  of  the  fistula.  Sometimes  one  operation  fails  to  cure, 
although  it  diminishes  the  size  of  the  fistula  very  much,  and  subsequent 
operations  must  be  resorted  to.  It  may  be  necessary  to  repeat  these  very 
frequently  before  success  is  attained. 

The  operation  of  Dr.  Sims  has  been  variously  altered  in  all  its  steps,  so 
that  now  the  number  of  modifications  is  quite  great,  so  great,  indeed,  that 
it  would  be  out  of  the  province  of  a  work  like  this  to  mention  them  in 
detail.  In  his  earlier  operations  Dr.  Sims  employed  the  quill  suture,  which 
he  called  the  clamp  suture,  but  a  tendency  on  the  part  of  the  little  metallic 
bars,  which  he  used  in  place  of  quills,  to  produce  ulceration,  induced  him 
to  resort  to  the  interrupted  suture. 

Other  methods  have  been  successfully  employed  by  Bozeman,  Agnew, 
Baker  Brown,  Simpson,  Simon,  and  others.  For  fear  of  being  uselessly 
prolix,  I  shall  describe  but  one  of  these,  that  of  Simon. 

Among  other  attempted  improvements,  Dr.  Startin  and  M.  Matthieu, 
of  Paris,  have  invented  hollow  needles,  through  which  the  silver  threads 
can  be  passed  without  first  passing  those  of  silk.  Extended  experience 
with  tubular  needles  leads  me  to  the  conviction  that  they  are  at  once  the 
most  ingenious  and  worthless  appliances  which  can  be  employed. 

Simon's  Operation. — No  one,  with  the  exception  of  Marion  Sims,  has 
labored  more  earnestly,  or  achieved  more  for  this  operation  than  Prof. 
Gustav  Simon,  of  Heidelberg.  Succeeding  Dietfenbach,  "Wutzer,  and 
Metzler,  who  had  themselves  accomplished  a  great  deal  in  advancing  the 
interests  of  the  operation  by  suture,  he  steadily  labored  with  the  means  at 
his  command,  and,  even  before  he  became  acquainted  with  the  improve- 
ments made  by  Sims,  had  acquired  a  great  degree  of  skill  in  treating 
vesico-vaginal  fistulne.  To  regard  him  as  an  imitator  would  be  unjust. 
He  was  without  question  a  coincident  discoverer. 

The  chief  features  of  Simon's  operation  are  these: — 

1st.   lie  repudiates  silver  wire  as  a  suture  superior  to  fine  silk. 

2d.  He  employs  an  exaggerated  lithotomy  position  in  place  of  the  left 
lateral  position. 

3d.  Instead  of  avoiding  the  mucous  membrane  of  the  bladder,  he  inten- 
tionally involves  it  in  his  abrasion. 

4th.  He  uses  no  stationary  catheter,  and  has  the  urine  drawn  only 
during  the  first  twenty-four  hours,  and  this  not  always. 

5th.   He  allows  the  bowels  to  be  evacuated  whenever  nature  prompts  it, 


URINARY    FrSTULJE TREATMENT. 


253 


ind  does  not  diet  the  patient  nor  confine  her  to  bed.  At  times  he  even 
permits  outdoor  exercise  in  twenty-four  hours  after  the  operation  in  favor- 
able cases. 

I  prefer  to  describe  his  procedure  as  far  as  possible  in  his  own  words. 
The  following  resume  of  his  method  is  made  up  from  his  work  upon  "The 
Operation  for  Vesico- vaginal  Fistula,"  published  in  18G2. 

"Position  of  Patient There  are  three  positions,  in  general  use,  for  the 

patient  in  operation  for  vesico-vaginal  fistula  :  (1)  The  back,  as  in  opera- 
tion for  stone;  (2)  the  knee-elbow;  and  (3)  Sims's  position,  which  is  a 
modification  of  the  latter.  "  I  use  neither  of  these,  but  prefer  the  breech- 
back  position  (Steiss-Riickenlage),  which  has  all  the  advantages  of  those 
mentioned,  without  their  disadvantages.  It  consists  in  this,  that  the 
patient,  lying  on  her  back,  is  put  in  a  position  which  is  almost  exactly 
similar  to  the  knee-elbow  position.  The  breech  is  so  elevated  that  it  is 
somewhat  above  the  level  of  the  abdomen  and  breast.     The  thighs  are 


Fig.  102. 


Simon's  position  for  vesico-vaginal  fistula.     (Simon.) 

bent  back  towards  the  belly  and  the  sides  of  the  chest,  so  that  the  breech 
is  the  most  projecting  part.  The  legs  are  either  flexed  at  the  knee,  or 
extended  over  the  sides  of  the  chest.  The  vulva  is  above  and  to  the 
front.  The  head  is  supported  by  a  pillow.  If  the  fistula  is  seated  very 
high  in  the  vagina,  the  thigh  must  be  drawn  as  far  as  possible  upwards ; 
if  the  fistula  is,  hoAvever,  very  near  the  vaginal  outlet,  we  are  not  obliged 
to  elevate  the  breech  so  much,  and  have  no  need,  therefore,  of  flexing  the 


254  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

thigh  so  forcibly.  I  have  called  this,  in  distinction  to  the  ordinary  back 
position,  the  tk  Steiss-riickenlage  ;"  because  in  it  the  breech  (Steiss)  is  the 
most  projecting  part,  and  presents  itself  in  a  manner  very  similar  to  the 
breech  presentation  of  the  foetus. 

The  advantages  are  : — 

1st.  The  Held  of  operation  is  clear,  we  are  not  obliged  to  operate  be- 
tween the  thighs. 

2d.  The  assistance  can  all  be  given  from  the  side,  without  hindering 
the  operator. 

oil.  It  allows  the  use  of  several  specula  and  the  side  retractors,  to  ex- 
pand the  vagina  on  every  side. 

4  th.  It  is  quite  as  well  borne  as  the  ordinary  back  position. 

5th.   It  admits  of  chloroform  narcosis 

If  the  fistula  can  be  brought  down  entirely  with  perfect  ease,  I  bring 
it  directly  to  light.  If,  however,  there  is  the  least  difficulty  in  moving  it, 
(as  in  the  majority  of  cases),  I  operate  with  the  specula  and  retractors, 
with  the  fistula  in  situ.  I  always  prove  this  by  seizing  the  uterus  with  a 
hooked-forceps  (Museux)  and  pulling  it  gently  down,  before  I  operate 
with  the  specula  and  levers.  I  have  improved  Jobert's  method  of  seizing 
the  cervix  with  the  forceps  by  passing  two  threads  through  the  cervix, 
thus  getting  rid  of  an  instrument  which  is  very  much  in  the  way.  Sims 
constructed  a  gutter-shaped  speculum  for  expanding  the  fistula,  which  has 
left  all  other  specula  in  the  background.  He  used  four  sizes.  It  is 
shaped  like  Neugebauer's  (1856),  except  that  instead  of  ending  in  a  sharp 
edge,  it  is  rounded  out  at  the  end.  I  have  found  the  use  of  this  speculum 
in  many  difficult  cases  absolutely  insufficient,  and,  in  the  majority  of  cases, 
it  only  answers  the  purpose  by  the  aid  of  other  instruments  to  expand  the 
vagina.  I  use,  therefore,  not  this  speculum  alone,  but  also  a  flat-shaped 
speculum  to  hold  up  the  other  vaginal  wall  and  also  side  levers  (shaped 
like  retractors),  to  hold  back  the  labia  and  sides  of  the  vagina.  All  these 
instruments  are  fixed  in  long  handles,  curved  at  the  end,  in  order  to  get 
them  out  of  the  way,  and  to  give  the  assistant  a  firm  grasp. 

Always  use  the  widest  specula  possible,  Sims's  are  not  wide  enough. 
I  have  had  two  sizes  more  made. 

In  addition  to  these  I  often  use  long-handled  hooks  to  seize  the  edges 
of  the  fistula.  I  always  cut  the  cord-like  contractions  of  the  vagina,  and 
have  even  cut  the  vaginal  folds  which  were  in  the  way. 

Vivifying  the  Edges. 

All  operators  have  tried  to  give  a  large  surface  for  union  without  en- 
larging the  wound.  They  have  done  this  by  cutting  at  the  expense  of 
tin;  vagina,  leaving  the  edges  of  the  bladder  intact.  According  to  my 
observations  and  experience,  I  give  the  preference  to  a  deep,  funnel-shaped 
incision  of  the  edges  of  the  fistula  similar  to  the  incision  in  plastic  opera- 


URINARY    FISTULA FRESHENING    THE    EDGES. 


•T, 


tions  in  any  other  part  of  the  body.  The  incision  must  be  carried  to  the 
healthy  tissue  and  all  the  cicatricial  tissue  extirpated. 

It  extends  quite  through  the  walls  of  the  septum  to  the  vesical  mucous 
membrane,  and  sometimes  through  it. 

In  this  way  is  formed  a  steep,  funnel-shaped  wound,  with  its  point  in 
the  bladder,  and  its  base  in  the  vagina,  and  its  edges  from  G  to  8  mm. 
thick. 

Fig.  103. 


Vivifying  the  edges  of  the  fistula.     (Simon.) 


Although  other  authors  wish  to  avoid  as  much  as  possible  the  enlarging 
of  this  defect,  it  is  exactly  here  only  wdiere  union  can  take  place  by  first 
intention,  that  I  strive  to  have  the  edges  as  free  from  cicatricial  substance, 
and  as  prone  to  union  as  possible ;  and,  even  in  the  largest  fistula,  I  do 
not  refrain  from  this  repeated  paring  off  the  edges,  even   to  making  the 


2o6  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

defect  very  much  larger,  until  the  union  is  accomplished.  And,  even  if 
with  the  best  preparation  of  the  edges,  the  union  dees  not  take  place,  and 
we  meet  with  entire  want  of  success,  the  woman  loses  no  more  urine  than 
before. 

Sometimes  I  cut  the  vesical  mucous  membrane,  and  sometimes  avoid 
it,  but  place  little  weight  on  that. 

The  advantages  claimed  are: — 

1st.  By  the  deep  funnel-shaped  incision  all  cicatricial  substance  will  be 
certainly  cleared  away. 

2d.  The  edges  are  more  prone  to  union,  as  they  unite  in  a  natural  man- 
ner, edge  to  edge,  and  not  with  a  flat  surface  on  the  same  ;  the  nerves, 
vessels,  etc.,  thus  continue  on  in  the  normal  direction. 

3d.  The  very  wide  edge  is  unnecessary,  as  only  the  upper  edges  unite 
in  any  case. 

4th.  If  union  does  not  take  place  the  first  time,  a  second  attempt  is 
more  likely  to  succeed,  with  the  thick  edges,  than  where,  with  already 
thin  edges,  these  must  be  bevelled  off  still  more  and  made  thinner. 

5th.  The  idea  that  catarrh  is  more  likely  to  follow  this  form  of  incision 
is  unfounded. 

Uniting  the  Edges  of  the  Wound. 

Method  of  Uniting — There  have  been  a  great  number  of  methods  of 
bringing  the  edges  together ;  all  of  which  accomplish  their  purpose,  but 
are  more  complicated  than  the  method  I  published  in  1854,  which,  with 
some  modification,  1  have  used  ever  since. 

In  order  to  meet  the  indication  for  uniting,  I  use  either  one  or  two  rows 
of  fine  silk  sutures  tied  in  the  ordinary  manner. 

In  large  fistuloe,  where  a  great  degree  of  relaxation  is  necessary,  in 
order  to  bring  the  edges  into  exact  union,  I  use  my  so-called  double 
suture,  consisting  of  two  rows,  one  the  'relaxing,'  the  other  the  'unit- 
ing.' In  small  or  in  slit-shaped  fistula?,  I  use  only  one,  the  uniting  row. 
In  the  double  suture,  one  row,  placed  very  deep  and  wide,  approaches  the 
tissues  surrounding  the  fistula,  to  the  line  of  union,  thus  relaxing  the 
edges ;  while  the  other,  placed  between  the  stitches  of  the  first,  holds 
firmly  the  edges,  and  thus  promotes  the  most  exact  union.  When  only 
one  is  used,  it  is  the  uniting  row,  and  placed  in  the  same  manner  as  here 
described.  Of  course,  each  row  of  sutures  supplements  the  other  in  its 
action. 

Both  rows  are  placed  very  deep,  even,  in  many  cases,  through  the  vesi- 
cal mucous  membrane.  They  thus  bring  the  edges  of  the  wound,  in  their 
whole  thickness,  in  the  closest  union,  and  withstand  greater  traction  than 
if  they  only  seized  a  part  of  the  edges.  The  sutures  are  1-1^  lines  apart. 
The  point  of  entrance  of  the  threads  is,  in  the  relaxing  suture,  some  dis- 


URINARY    FISTULA AFTER-TREATMENT, 


257 


tance  from   the  edge,  in   the   uniting,  quite   near.     I  consider  it  of  very 
little  importance,   whether   the   suture   goes    through   the  vesical  mucous 


Fig.  104. 


Sutures  in  position.     (Simon.) 

membrane  or  not.     It  is  only  necessary  to  be  careful  that  this  membrane 
does  not  get  between  the  edges  of  the  wound. 

After-  Treatment. 

1st.  From  a  series  of  observations,  I  conclude  that  neither  on  the 
wound  nor  on  the  new  cicatrix  does  the  urine  have  any  injurious  influ- 
ence, and  neither  hinders  the  union  by  primary  intention  nor  loosens  a 
once  formed  cicatrix. 

2d.  From  another  series  of  observations,  I  have  learned  that  the  heal- 
ing is  not  interfered  with  by  a  degree  of  distention,  which  could  come  in 
17 


258  FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 

a  normal  filling  of  the  bladder,  provided,  only,  that  the  wound  is  perfectly 
freshened  and  united. 

In  most  cases  the  permanent  retention  of  the  catheter  only  does  harm. 

Each  of  these  deductions  is  drawn  from  a  number  of  appropriate  cases. 

Upon  these  conclusions  then  is  based  my  after-treatment,  which  up  to 
the  removal  of  the  stitches  is  entirely  unimportant.  Those  minute  direc- 
tions, the  carrying  out  of  which  is  so  tedious  both  for  the  patient  and 
physician,  are  all  laid  aside.  The  patient  is  permitted  to  take  any  posi- 
tion she  chooses.  She  passes  her  water,  as  soon  as  she  feels  the  need, 
either  in  a  bed-pan,  or,  if  she  object  to  that,  in  the  sitting  or  knee-elbow 
position.  Only  in  a  few  cases,  where  the  patient  is  not  in  a  condition  to 
pass  water  spontaneously,  is  the  catheter  used  every  three  or  four  hours. 
On  the  fourth  or  fifth  day  an  attempt  is  made  to  remove  the  stitches,  and 
this  is  repeated  on  the  following  days.  On  the  eighth  day,  the  patient  is 
allowed  to  leave  her  bed,  even  if  all  the  stitches  are  not  out. 

To  avoid  passages  from  the  bowels,  with  straining,  on  the  first  eight 
days,  a  fluid  discharge  is  recommended.  If  irritation  of  the  bladder  en- 
sue, morphine,  one-eighth  grain  per  dose,  should  be  given,  and  daily  warm 
injections  into  the  vagina,  but  not  into  the  bladder,  should  be  employed."1 

Prof.  Simon2  reports  the  following  results  :  "  Of  1 18  fistula?  occurring  in 
105  patients,  there  were  104  fistula?  in  92  patients  cured  completely  (a 
later  cure  is  counted  in  under  the  first  category)  ;  5  fistula?  in  5  patients 
almost  entirely  closed ;  2  patients  with  3  fistula?  discharged  as  incurable  ; 
G  patients  died." 

In  the  description  of  Simon's  method  here  given,  the  words  of  the 
author  have  been  employed  as  much  as  possible,  and  now,  in  concluding 
my  account  of  it,  I  proceed  to  express  my  opinion  as  to  its  value  as  com- 
pared with  that  of  Sims.  In  a  very  few  rare  cases  of  extensive  destruc- 
tion of  the  base  of  the  bladder  in  women  who  are  exceedingly  obese,  it 
answers  a  better  purpose  than  that  of  Sims  ;  but,  as  a  rule,  it  is  difficult  to 
appreciate  how  any  one  who  has  tried  both  can  consider  the  former  as 
comparable  to  the  latter.  Indeed  it  may  justly  be  said  that  Sims's  method 
leaves  *o  little  to  be  desired  that  all  others  are  completely  overshadowed 
by  it. 

Elytroplasty. — This  operation  was  published  to  the  profession  by  Jo- 
bert  de  Lamballe,1  in  1834,  and  was  subsequently  altered  and  improved 
by  Velpeau,  Gerdy,  and  Leroy  d'Etiolles.  It  consists  in  dissecting  a  flap 
from  one  buttock  (Jobert),  or  the  posterior  wall  of  the  vagina  (Velpeau 
and  Leroy),  and  fixing  it  by  sutures  into  the  orifice  of  the  fistula,  the  bor- 

1  This  resume"  has  been  prepared  from  Prof.  Simon's  work  by  Dr.  M.  D.  Mann. 

2  Am.  Journ.  Obstet.,  vol.  ii.  p.  241. 

»  Bull,  de  l'Acad.  de  Med.  de  Paris,  t.  ii.  p.  145. 


URINARY    FISTULiE — CLOSURE    OF    THE    VAGINA.  259 

ders  of  which  have  been  previously  pared.  It  resembles  the  operations  of 
rhinoplasty  performed  upon  the  face,  but  is  unfortunately  even  more  dilli- 
cult  than  they,  and  calls  for  such  great  manual  dexterity  as  to  preclude  its 
frequent  adoption.  Velpeau,  by  making  two  parallel,  longitudinal  incis- 
ions in  the  vagina,  dissected  up  the  intervening  tissue  and  stitched  it  to 
the  edges  of  the  fistula. 

Leroy  prolonged  these  incisions  to  the  vulva,  dissected  up  the  inter- 
vening flap,  and,  rolling  this  upon  itself,  applied  its  under  or  bleeding 
surface  against  the  fistula. 

Elytroplasty  is  still  employed  sometimes  where  great  destruction  of  tis- 
sue has  taken  place  at  the  base  of  the  bladder,  but  the  difficulties  and 
uncertainties  attending  it,  together  with  the  fact  that  more  simple  and 
efficient  methods  for  dealing  with  this  class  of  cases  are  at  command,  have 
rendered  a  resort  to  it  very  rare. 

To  one  unaccustomed  to  the  treatment  of  fistulas,  it  would  appear  that 
the  larger  the  fistula  the  more  difficult  would  be  its  cure.  This  is  not  so ; 
some  of  the  most  difficult  cases  will  be  found  to  be  those  in  which  the 
opening  is  so  small  as  to  be  discerned  with  difficulty.  In  these  cases  I 
would  strongly  recommend  the  following  plan.  Introduce  into  the  bladder 
a  large  steel  sound,  and  by  its  extremity  make  the  fistula  to  project  to- 
wards the  vagina ;  then  cut  away  the  tissue  surrounding  the  fistula  so  as 
to  let  the  sound  pass  freely  into  the  vagina.  Sutures  may  then  be  passed, 
and  the  enlarged  fistula  cured. 

Closure  of  the  Vagina. 

This  procedure  is  resorted  to  in  despair  of  accomplishing  the  cure  of  the 
fistula,  and  in  the  hope  of  relieving  the  patient  from  the  intolerable  an- 
noyance attendant  upon  an  involuntary  and  constant  discharge  of  urine. 
It  does  not,  of  course,  equal  in  efficiency  closure  of  the  vesical  fistula, 
since  it  involves  the  necessity  of  the  urine  being  retained  in  the  vaginal 
canal,  which  is  injured  by  its  presence,  and  is  proposed  only  for  those  cases 
in  which,  from  extensive  destruction  of  tissue,  no  hope  of  closure  by  su- 
ture or  elytroplasty  can  be  entertained.  By  it  the  vagina  and  bladder  are 
rendered  a  common  receptacle  for  urine  and  menstrual  blood,  the  only 
advantage  gained  consisting  in  the  fact  that  they  may  be  retained  and 
discharged  at  will  through  the  urethra  which  remains  open. 

Closure  of  the  vagina  may  be  accomplished  by  two  operations,  episior- 
rhaphy  and  obliteration  of  the  canal.  The  first,  which  consists  in  paring 
the  inner  surfaces  of  the  labia  majora  and  uniting  them  by  sutures  so  as 
to  cause  their  complete  adhesion,  originated  with  Vidal  de  Cassis,  who 
performed  it  in  1833.  The  operation  is  exceedingly  simple  in  its  steps, 
but  a  very  minute  opening  almost  invariably  remains  just  under  the  mea- 
tus through  which  a  little  urine  exudes.     This  very  nearly  invalidates  the 


260 


FISTULA    OF    THE    FEMALE    GENITAL    ORGANS. 


success  of  the  method,  for  even  a  slight  escape  renders  the  patient  uncom- 
fortable. 

The  second  consists  in  paring,  not  the  labia,  but  the  vaginal  walls. 
Strips  of  mucous  membrane  being  thus  taken  away,  the  bleeding  surfaces 
are  brought  in  contact  by  suture,  and  the  bladder  is  kept  empty  by  a 
catheter  until  union  has  occurred.  This  procedure,  a  far  more  valuable 
and  reliable  one  than  that  of  Vidal,  was  first  performed  by  Simon,  who 
has  applied  to  it  the  name  of  "  Kolpokleisis,"  or  cross  obliteration.  Prof. 
Simon's  first  operation  was  performed  in  1855,  and  since  that  time  he 
declares  that  it  has  been  resorted  to  in  Germany  in  over  fifty  cases  with 
complete  success,  and  many  cases  suffering  from  incontinence  of  urine  due 

Fig.  105. 


Obliteration  of  the  vagina.     (Simon.) 


to  great  loss  at  the  base  of  the  bladder  have  been  entirely  relieved  by  it. 
He  places  a  very  high  estimate  upon  the  operation,  as  the  following 
extract  from  a  published  letter  from  him  to  Dr.  Bozeman  of  this  city  will 

show  : — 


VESICO-UTERINE    FISTULA, 


2G1 


"  The  reason  why  I  have  proved  the  validity  of  my  claims  of  priority  at 
such  lengths,  is  simply  this,  that  in  my  opinion  kolpokleisis  is  the  most  im- 
portant plastic  operation  which  in  the  last  decennia  has  originated  from  one 
single  man.  The  operation  of  vesico-vaginal  fistula  hy  uniting  the  borders 
of  the  defect  is  indeed,  in  its  present  perfection  and  precision,  a  much  more 
important  acquisition  than  kolpokleisis,  and  probably  the  greatest  achieve- 
ment of  our  century  in  plastic  surgery  ;  but  it  has  not  been  carried  to  that 
perfection  by  a  single  man,  but,  on  the  contrary,  operators  of  all  nations 
have  contributed  their  share  to  it.  The  '  uranoplastie'  of  our  ingenious 
countryman — von  Langenbeek — could  alone  be  placed  by  the  side  of  kolpo- 
kleisis, as  far  as  the  safety  of  the  performance  and  its  immediate  success  are 
concerned.  It  would  rank  higher  still  on  account  of  its  more  frequent  oc- 
currence, if  its  benefit  for  the  voice  in  increasing  its  purity  could  be  secured 
in  all  or  the  majority  of  cases.  But  as  in  many  cases  this  result  is  not  ob- 
tained at  all  and  in  others  only  incompletely,  kolpokleisis  must  be  considered 
the  more  important  operation,  as  in  all  cases  it  fully  answers  its  purpose. 
This  operation,  which  I  invented  at  the  time  when  the  obliteration  of  the 
vulva,  proposed  by  Vidal,  proved  inefficacious  in  re-establishing  continence 
of  urine,  has  already  been  performed  more  than  fifty  times  with  complete 
success.  Through  it  many  patients  with  incurable  defects  of  the  bladder 
have  been  freed  of  the  most  intolerable  suffering,  viz.,  incontinence  of  urine. 
I  have  nvyself  succeeded  in  eighteen  cases  in  effecting  perfect  obliteration, 
and  every  German  surgeon  who  practises  the  art  of  curing  vesico-vaginal 
fistules  has  recorded  one  or  more  successful  cases  of  that  kind." 

In  his  earlier  operations,  Prof.  Simon  confined  this  procedure  to  the 
lower  section  of  the  vagina,  but  he  now  obliterates  the  canal  just  below 
the  loss  of  substance. 


Fig.  106. 


Urinary  Fistulas  requiring  Special  Treatment. 

In  the  great  majority  of  instances  no  other  plan  of  treatment  than  the 
suture  is  necessary.     There   are,  however,  some 
cases  of  urinary  fistulae  in  which  the  application  of 
the  suture  is  difficult,  or  even  impossible.     These 
will  now  engage  our  attention. 


Vesico-uterine  Fistidce. 

Jobert  first  pointed  out  the  proper  method  for 
reaching  these.  His  plan  is  not  at  present  em- 
ployed, but  that  now  regarded  as  most  reliable 
is  only  a  modification  of  it.  It  consists  in  slitting 
up  the  anterior  lip  of  the  uterus  until  the  fistula 
is  reached,  vivifying  its  edges,  and  passing  sutures 
directly  through  the  cervix,  as  represented  in  Fig. 
106,  so  as  to  approximate  the  walls  of  the  cervix 
and  the  lips  of  the  fistula. 

In  case  the  fistulous  orifice  be  so  high  as  to  be 


The  cervix  is  slit  to  ex- 
pose the  fistula  above,  and 
sutures  are  passed. 


2G2 


FISTULA    OF    THE    FEMALE    GENITAL    ORGANS, 


considered  beyond  reach,  the  only  remaining  resource  is  to  close  the  os  uteri 
externum  by  suture,  and  allow  menstruation  to  occur  through  the  bladder. 

Vesico-utero-vaginal  Fistulce. 

For  these   the   plan  of  vivifying  the  anterior  lip  of  the  os,  and  thus 
making  the  uterine  tissue  subservient  to  closure  of  the  fistula,  is  peculiarly 

Fig.  107. 


Anterior  lip  of  fistula  united  to  anterior  lip  of  cervix.     (Simon.) 

applicable.  The  operation,  represented  at  Fig.  107,  is  similar  to  that  for 
ordinary  vesico-vaginal  fistula,  the  only  difference  being  that  one  lip  of 
the  fistula  is  made  of  the  vivified  cervix  uteri. 

In  case  the  anterior  lip  of  the  uterine  neck  be  so  completely  destroyed 

that  it  cannot  furnish  the  requisite 
Fig.  108.  tissue  for  this  purpose,  the  vagina 

may  be  united  to  the  posterior  lip 
so  as  to  throw  the  cervix  into  the 
bladder.  Menstruation  will  after- 
wards occur  into  that  viscus,  and 
the  blood  thus  accumulating  be 
discharged  with  the  urine. 


Fistulce  with  Extensive  Destruction 
of  the  Base  of  the  Bladder. 

It  has  already  been  mentioned 
that  elytroplasty  and  kolpokleisis 
offer  resources  in  these  cases.  To 
Dr.  Bozeman,  however,  we  are 
indebted  for  still  another  procedure, 
the  first  step  of  which  consists  in 


Anterior  lip  of  fistula  united  to  pontcrior  lip  of 
cervix.     (Simon.) 


URETERO-UTERINE    AND    URETERO- VAGINAL    FISTULA.       203 

dragging  the  uterus  down  daily  for  weeks  before  the  operation  by  means 
of  a  pair  of  foreeps  by  which  the  neck  is  seized.  In  this  way  the  uterus 
is  made  to  approximate  the  vulva.  Then  one  lip  of  the  cervix,  being 
vivified,  is  brought  into  contact  with  the  extremity  of  the  remains  of  the 
vesico-vaginal  septum,  and  firmly  united  with  it  by  suture. 

To  facilitate  this  procedure,  the  cervix  may  with  great  advantage  be 
slit  to  the  vaginal  junction,  drawn  forward  and  made  to  fill  the  space  left 
vacant  by  the  sloughing  of  the  vagina. 

Uretero-uterine  and  TJretero-vaginal  Fistulee. 

In  addition  to  the  varieties  of  urinary  fistula?  mentioned  here,  certain 
rare  instances  of  union  between  the  ureters  and  vagina  or  uterus  have 
been  recorded.  A  striking  example  of  uretero-uterine  fistula  may  be 
found  detailed  in  the  Dictionnaire  de  Medecine,  vol.  xxx.,  by  M.  Berard. 
It  is  not  only  interesting  in  itself,  but  as  displaying  the  method  by  which 
the  diagnosis  may  be  arrived  at  is  worthy  of  special  mention.  Regarding 
it  at  first  as  a  vesico-uterine  fistula,  from  the  fact  that  urine  was  dis- 
charged from  the  uterus,  he  arrived  at  a  different  diagnosis  from  these 
facts : — 

1st.  The  urine  flowed  steadily  from  the  cervix  when  the  bladder  was 
empty. 

2d.   The  urine  thus  flowing  was  limpid,  unlike  that  from  the  bladder. 

3d.  The  patient  being  kept  seated  over  a  vessel  for  two  hours  so  as  to 
preserve  all  the  urine  flowing  per  vaginam,  a  catheter  was  passed  into  the 
bladder  and  the  amount  removed  exactly  equalled  that  which  had  escaped 
vicariously. 

4th.  Injecting  the  bladder  with  fluid  colored  by  indigo,  the  urine  pass- 
ing per  vaginam  remained  limpid. 

5th.  A  sound  being  passed  into  the  uterus  and  another  into  the  bladder, 
their  points  could  not  be  brought  into  contact. 

Uretero-uterine  fistula  is  by  no  means  common ;  only  one  instance  is 
mentioned  by  Dr.  Emmet  in  his  recent  work  as  having  occurred  in  his 
extensive  experience.  Dr.  W.  H.  Baker,1  of  Boston,  has  recently  pub- 
lished an  interesting  case,  which  was  cured  by  dissecting  up  the  ureter 
which  ended  at  a  point  near  the  meatus  urinarius,  making  an  opening 
near  the  neck  of  the  bladder,  turning  the  ureter  into  this,  and  then  closing 
the  vaginal  wound. 

Dr.  Henry  F.  Campbell,2  of  Georgia,  reports  an  interesting  case  of 
uretero-vaginal  fistula  which  he  cured  by  this  simple  procedure  :  passing 
a  small  bistoury  up  the  ureter,  he  slit  its  anterior  wall,  the  knife  passing 

1  N.  Y.  Med.  Journal,  Dec.  1878. 

2  Ainer.  Journ.  Med.  Sciences,  Jan.  1880. 


264  FISTULiE    OF    THE    FEMALE    GENITAL    ORGANS. 

into  the  bladder.     He  then  closed  the  vaginal   surface  of  the  cut  thus 
made  with  silver  suture.     The  patient  rapidly  and  entirely  recovered. 

An  exceedingly  interesting  instance  of  this  variety  of  fistula  is  men- 
tioned by  Zweifel,  of  Erlangen,  in  which  he  removed  the  kidney  of  the 
diseased  side  with  a  successful  result.  The  right  kidney  which  was  left 
proved  quite  sufficient  for  the  wants  of  the  economy. 

There  are  eccentric  and  rare  forms  of  fistula  which  I  have  not  men 
tioned  in  my  enumeration.  For  example,  I  have  met  with  a  case  of 
vesico-abdominal  fistula.  Eight  days  after  the  operation  of  ovariotomy, 
about  one  pint  of  urine  began  to  pass  daily  through  the  abdominal  open- 
ing, the  lower  angle  of  which  had  been  kept  open  for  washing  out  the 
peritoneum.  That  the  fistula  was  vesical  and  not  ureteral  was  proved  by 
the  escape  of  colored  fluid  through  the  abdominal  wound  when  injected 
into  the  bladder.  This  patient  entirely  recovered,  and  the  fistula  healed 
of  itself. 

"Where  a  larger  extent  of  denuded  surface  is  required  than  can  be  ob- 
tained by  paring  the  edges  of  fistulae,  Langenbeck  and  Colles  have  resorted 
to  the  following  plan.  Splitting  the  edges  of  the  fistula,  they  have  sepa- 
rated the  two  flaps  thus  produced,  and  bringing  the  opposing  raw  surfaces 
together,  have  secured  them  by  suture. 

Treatment  of  Long,  Tortuous,  Capillary  Sinuses  remaining  after 
Operation  by  Suture. 

Sometimes  fistula?  situated  near  and  involving  the  neck  of  the  uterus 
will  be  cured  in  great  part  by  suture,  and  yet,  at  one  or  both  extremities 
of  the  original  opening,  long,  capillary  sinuses  will  remain,  which,  running 
a  tortuous  course,  reach  the  bladder  and  render  the  operation  a  failure. 
Under  these  circumstances  it  is  almost  impossible  to  pare  the  edges  of 
these  tracts  by  knife  or  scissors,  and  the  cautery  which  has  been  generally 
used  for  them  commonly  fails  to  cure  them.  For  these  I  have  adopted 
with  the  most  satisfactory  results  the  following  plan.  Having  a  dentist's 
burr  made  with  cutting  flanges,  instead  of  dull  ones,  such  as  are  usually 
employed,  it  is  fitted  to  the  ordinary  dentist's  treadle;  as  the  burr  is  made 
to  revolve  rapidly  by  the  action  of  an  assistant's  foot,  it  is  passed  up  and 
down  the  sinus  to  be  closed  several  times  until  the  operator  feels  that 
the  entire  canal  is  thoroughly  denuded.  Then  by  curved  needles,  deep 
sutures  are  passed  approximating  its  vivified  walls. 

By  this  means  I  have  cured  several  fistula?  situated  just  in  contact 
with  the  cervix  uteri,  which  would  have  been  exceedingly  difficult  of  cure 
by  any  other  method.  It  has  the  advantage  of  being  very  expeditious, 
and  I  would  unre  its  claims  in  this  class  of  cases. 


FECAL    FISTULA.  L'ljf) 


CHAPTER    XVI. 

FECAL  FISTULA. 

Definition These,  which   are    much    less    frequently  met   with   than 

urinary  fistulae,  consist  in  communications  established  between  the  vagina 
or  vulva  and  some  part  of  the  intestinal  tract. 

Varieties They  may  be  recto-vaginal,  entero-vaginal,  or  recto-labial ; 

the  first  being  the  most  common,  and  the  second  the  rarest  of  the  varieties. 

Causes. — The    causes    which   produce   them  are  almost  identical  with 
those  which  result  in  urinary  fistulae,  viz.  : — 
Prolonged  pressure  ; 
Direct  injury ; 
Ulceration  or  abscess. 

The  first  of  these  may  produce  them,  as  it  does  those  occurring  on  the 
anterior  vaginal  wall,  by  creating  an  intense  inflammation  which  results  in 
sloughing,  or  the  intensity  of  the  pressure  may  be  so  great  as  rapidly  to 
destroy  the  vitality  of  the  part.  Such  pressure  is  most  frequently  the 
result  of  difficult  parturition,  but  in  rare  cases  it  may  arise  from  badly- 
fitting  pessaries  or  scybalous  masses  in  the  rectum. 

Direct  injury  by  instruments  used  in  delivery,  or  others  employed  for 
removal  of  impacted  feces,  may  evidently  produce  them. 

Ulceration  or  abscess  much  more  frequently  produces  fecal  than  urinary 
fistuue.  For  the  recto-vaginal  variety  stricture  of  the  rectum  is  a  fruitful 
source,  the  stricture  producing  a  retention  of  fecal  matters  which  excites 
ulceration  that  may  extend  to  the  vaginal  canal.  An  abscess  between  the 
vagina  and  rectum  may  cause  a  communication  between  the  two,  or  bur- 
rowing towards  one  labium  may  open  there  and  connect  this  part  by  a 
tract  with  the  rectum.  In  the  same  manner  a  purulent  collection  has 
been  known  to  make  a  junction  between  the  caput  coli  and  vagina. 
Lastly,  syphilitic  and  cancerous  ulceration  may  open  a  channel  between 
the  intestinal  and  vaginal  canals. 

Symptoms — The  most  prominent,  often  the  only  symptom  which  will 
attract  the  patient's  attention,  will  be  a  discharge  of  offensive  gas  or  fecal 
matter  by  the  vagina.  The  amount  which  escapes  will  of  course  be 
governed  by  the  size  of  the  fistula,  but  the  annoyance  dependent  upon  the 
accident  will  not  be  so,  for  even  the  smallest  quantity  will  be  sufficient  to 
render  the  patient  utterly  wretched  by  the  offensive  odor  to  which  it  gives 
rise. 


266 


FECAL    FISTOLiE. 


Physical  Signs The  patient  being  placed  upon  the  back,  touch  should 

be  practised  upon  all  the  surface  of  the  vagina.  If  the  fistula  be  one  of 
any  magnitude,  this  will  at  once  discover  it.  If  not,  careful  exploration 
by  the  speculum  will  almost  always  do  so.  Sims's  speculum  should  be 
introduced  under  the  symphysis  so  as  to  lift  the  anterior  wall  of  the  vagina 
while  the  lateral  walls  are  held  aside  by  spatulae.  Should  visual  explora- 
tion not  reveal  the  opening,  the  rectum  may  be  filled  with  tepid  water 
colored  with  cochineal  or  indigo,  and  its  escape  carefully  watched  for. 

Propjiosis Fecal  fistula?  are  more  likely  to  be  spontaneously  recovered 

from  than  those  of  urinary  character,  from  the  fact  that  they  give  passage 
to  gaseous  and  semi-fluid  excretions,  and  not  to  an  irritating  fluid  which 
is  constantly  dribbling  away  and  keeping  the  fistulous  walls  from  uniting. 
But  even  these  are  rarely  recovered  from  unless  surgical  aid  be  brought 
to  their  relief. 

Fig.  109. 


Examination  for  fecal  fistula. 


Treatment. — Recto-vaginal  and  recto-labial  fistula?  should  always  be 
treated  by  suture. 

This  is  practised  upon  the  same  plan  as  that  which  is  followed  in 
vesico-vaginal  fistulae,  with  these  exceptions,  that  the  patient  is  placed  in 
the  position  adopted  in  operating  for  stone,  and  that  the  speculum  is  so 
inserted  as  to  elevate  the  anterior  instead  of  the  posterior  vaginal  wall. 
Before  operation,  the  sphincter  ani  muscle  should  always  be  paralyzed  by 
thorough  stretching  by  the  fingers,  and  after  it  a  rectal  tube  should  be 
retained,  unless  very  annoying  to  the  patient.  After  the  operation,  too, 
the  reetum,  which  should  have  been  thoroughly  emptied  by  enema  before 
it,  should  be  kept  perfectly  quiet  by  opiates  for  ten  or  twelve  days.   When 


SIMPLE    VAGINAL    FISTULA.  267 

evacuations  are  first  permitted,  laxatives  should  be  employed  in  order 
to  avoid  tenesmus,  which  might  destroy  the  union  of  the  lips  of  the 
fistula. 

In  one  case  of  recto- vaginal  fistula  I  have  introduced  the  speculum  into 
the  rectum,  and  closed  the  fistula  on  the  rectal  surface.  The  facility  with 
which  the  operation  was  performed  was  surprising.  Should  the  fistula 
exist  only  a  short  distance  above  the  sphincter  ani,  the  best  method  of 
treatment  is  to  cut  completely  through  the  perineal  body,  vivify  carefully, 
and  close  the  wound. 

Entero-Vaginal  Fistulae. 

Entero-  Vaginal  Fistula,  which  consists  in  a  fistulous  tract  between 
some  part  of  the  intestinal  canal  above  the  rectum,  and  the  vagina,  is  rare, 
and  when  existing  should  be  looked  upon  as  an  artificial  anus,  the  closure 
of  which  would  be  attended  by  danger.  If  the  opening  be  direct  and  there 
be  no  tract  leading  from  one  canal  to  the  other,  this  would  not  be  the  case, 
but  if  a  tract  exist,  the  closure  of  its  vaginal  extremity  would  probably 
result  in  abscess  excited  by  fecal  matters  passing  out  of  the  intestine. 

Simple  Vaginal  Fistulae. 

Definition Under  this  head  are  grouped  those  forms  of  fistulous  con- 
nection with  the  vagina  which  do  not  act  as  vicarious  outlets  for  any  neigh- 
boring organ,  as,  for  example,  peritoneo-vaginal,  perineo-vaginal,  and 
blind  fistula?. 

Peritoneo-vaginal  Fistula  has  been  rarely  met  with.  When  it  does 
occur  it  is  attended  by  danger  of  descent  of  the  intestine  into  the  vagina, 
and  entrance  of  fluids  and  air  into  the  peritoneal  cavity.  One  reason  for 
its  rarity  is  probably  the  fact,  that,  no  excrementitious  substance  passing 
through  it,  it  very  generally  disappears  without  becoming  chronic.  Should 
it  not  do  so,  no  annoyance  would  arise  from  its  existence,  and  it  would  be 
susceptible  of  immediate  cure  by  suture. 

Perineo-vaginal  Fistula  may  result  from  partial  closure  of  a  ruptured 
perineum  leaving  a  small  orifice  near  the  sphincter  ani,  or  from  penetra- 
tion of  the  presenting  part  of  the  fetus  through  the  perineum.  It  may  be 
readily  cured  by  incision,  ligature,  cauterization,  or  injection,  after  the 
plan  just  pointed  out  in  connection  with  fecal  fistulse. 

Blind  vaginal  Fistulae  are  those  which  lead  to  a  purulent  collection  in 
some  part  of  the  pelvis.  They  will  be  fully  treated  of  when  considering 
pelvic  abscesses,  and  nothing  need  be  said  of  them  here  further  than  to 
mention  the  principles  upon  which  their  treatment  rests  :  1st,  dilatation 
of  the  fistulous  tract  by  tents  or  incision  ;  2d,  exerting  an  alterative  action 
on  the  walls  of  the  abscess  by  iodine,  iron,  nitrate  of  silver,  Avater,  etc.  etc. 


208  ACUTE    ENDOMETRITIS. 


CHAPTER   XVII. 

ACUTE  ENDOMETRITIS. 

I  freely  confess  that  the  arrangement  of  no  subject  treated  of  in  this 
work  has  caused  me  more  perplexity,  and  is  offered  to  the  reader  with 
greater  hesitancy,  than  that  which  relates  to  the  divisions  of  endometritis. 
Having  personally  no  theory  to  sustain  in  reference  to  the  matter,  my  sole 
desire  is  to  present  the  subject  in  the  manner  which  will  best  aid  in  its 
comprehension,  assist  the  practitioner  at  the  bedside,  and  favor  a  future 
advance  in  its  pathology. 

Throughout  the  literature  of  gynecology  admissions  will  everywhere  be 
found  of  the  fact  that  endometric  inflammation  limits  itself  to  the  neck, 
the  body,  or  even,  according  to  one  authority,1  to  the  fundus  of  the  uterus, 
and  yet  the  two  varieties  of  the  affection  are  treated  of  as  one,  and  one 
author2  even  goes  so  far  as  to  assert  that  "  the  facility  for  locating  its  limit 
exclusively  to  cervix,  body,  or  fundus  rests  only  in  the  brain  of  the 
theorist."  Barnes  treats  of  the  whole  subject  as  "  endometritis,"  yet, 
with  characteristic  candor,  he  says,  "  it  appears  to  me  that  attention  has 
been  too  strictly  fixed  upon  the  visible  changes  in  the  cervix  and  os  uteri  ; 
and  that,  thus  engrossed,  the  mind  has  been  closed  against  the  less  telling 
evidence  of  changes  in  the  body  of  the  uterus." 

All  things  being  carefully  considered,  I  have  thought  it  best  to  adhere 
to  the  arrangement  which  follows,  guarding  the  reader  against  the  idea 
that  any  facility  of  differentiation,  any  dogmatic  certainty  of  conclusion  is 
claimed  in  reference  to  the  matter.  The  arrangement  simply  seems  to  me, 
for  many  reasons,  that  which  best  meets  the  requirements  of  the  present 
and  favors  the  prospects  of  the  pathology  of  the  future. 

The  varieties  of  inflammation  of  the  lining  membrane  of  the  uterus  may 
be  clearly  expressed  in  the  following  manner : — 

i  General. 
Acute     -<  Cervical. 
(  CorporeaL 


Endometritis  < 


c  General. 
Chronic  <  Cervical. 
(  Corporeal. 


1  Dr.  Routh's  article  on  "Fundamental  Endometritis." 

2  Dr.  T.  A.  Emmet,  op.  cit. 


causes.  2G9 

Synonyms. — Acute  endometritis  has  been  treated  of  under  the  names 
of  acute  uterine  leucorrhoea,  acute  uterine  catarrh,  acute  internal  metritis. 

Frequency Acute  inflammation  of  the  lining  membrane  of  the  uterus 

is  a  condition  which  occurs  quite  frequently.  Often  running  a  rapid 
course,  however,  and  ending  in  recovery  or  in  chronic  disease,  it  passes 
unrecognized  in  many  cases.  In  this  way  I  would  explain  many  of  the 
cases  of  suppressio  mensium  and  congestive  dysmenorrhea,  which  we  so 
often  find  ending  in  chronic  disease.  And  thus  also  would  I  account  for 
the  profuse  and  painful  attacks  of  leucorrhoea  occurring  with  exanthema- 
tous  fevers,  and  lasting  for  a  length  of  time  after  they  have  passed  off. 
It  is  very  generally  stated  that  acute  metritis  is  seldom  met  with  except 
as  a  sequel  of  parturition,  and  I  agree  in  the  statement  as  applying  to 
parenchymatous  inflammation,  but  it  does  not  apply  to  endometritis,  which 
often  proves  the  source  of  sudden  menstrual  disorder  and  the  cause  of 
violent  leucorrhoea. 

Varieties — The  morbid  process  may  affect  the  lining  membrane  of  the 
cervix  or  of  the  body  alone,  or  it  may  attack  the  whole  uterine  mucous 
tract,  its  selection  of  site  being  governed  by  its  cause.  Thus,  that  form 
which  immediately  follows  parturition  or  abortion,  or  results  from  gonor- 
hcea,  is  likely  either  to  affect  the  whole  mucous  tract  or  the  cervical  canal 
alone  ;  while  that  which  is  due  to  sudden  checking  of  the  menstrual  flow 
is  more  likely  to  be  confined  to  the  body. 

Causes — The  causes  of  acute  endometritis  are  the  following  : — 
Direct  injury ; 

Cold  from  exposure  during  menstruation  ; 
Constitutional  disease  of  septic  or  asthenic  character; 
Vaginitis,  specific  or  simple  ; 
Excessive  venery; 
Suppression  of  menstruation. 
Examples  of  direct  injuries  which  may  produce  acute  endometritis  are 
the  introduction  of  the  uterine  sound  or  the  intra- uterine  pessary,  the  em- 
ployment of  tents  or  the  application  of  chemical  irritants,  surgical  opera- 
tions, and  intemperate  coitus. 

It  is,  probably,  in  some  instances,  through  the  instrumentality  of  this 
disease  that  those  cases  of  fatal  peritonitis  which  result  from  tents,  sounds, 
and  intra-uterine  pessaries  occur.      Inflammatory  action  is  first  set  up  in 
the  lining  membrane  of  the  uterus,  and  thence  swiftly  passes  through  the  ' 
Fallopian  tubes  to  the  peritoneum. 

Specific  vaginitis  or  gonorrhoea  will  sometimes  pass  up  into  the  cervix 
and  body  of  the  uterus,  and  out  through  the  Fallopian  tubes,  creating  pel- 
vic peritonitis  of  most  violent  character.  Even  simple  vaginitis,  when  of 
very  severe  form,  may  produce  endometritis,  though  this  is  by  no  means 
common. 

The   peculiar  blood   state,  attending  upon  and  forming  an  element  of 


270  ACUTE    ENDOMETRITIS. 

measles,  scarlatina,  variola,  and  roseola,  and  exerting  its  influence  on  all  the 
mucous  linings  of  the  body,  will  sometimes  result  in  general  endometritis, 
and  the  hemic  condition  resulting  from  phthisis  not  rarely  does  so.  Kiwisch 
has  styled  this,  "metastatic  constitutional  catarrh." 

Exposure  to  cold  and  moisture,  great  mental  anxiety,  or  any  other  in- 
fluence which  suddenly  checks  the  menstrual  flow,  not  infrequently  pro- 
duces this  disease.  At  the  moment  of  exposure  suppressio  mensium,  or 
congestive  dysmenorrhea,  may  take  place,  and  from  that  time  endometritis 
may  exist.  "When  we  consider  that  such  a  sudden  check  of  menstruation 
will  sometimes  result  in  hematocele  of  fatal  character,  it  is  certainly  not 
to  be  wondered  at  that  it  may  likewise  produce  the  disease  of  which  we 
are  speaking. 

Excessive  venery,  even  where  no  violence  is  done  to  the  uterus,  may 
produce  it  by  the  prolongation  of  intense  congestion  of  the  organ  kept  up 
by  this  act. 

Symptoms The  disease  demonstrates  its  presence  in  the  non-puerperal 

uterus  without  any  very  violent  symptoms. 

Ordinarily  the  patient  complains  of  pain,  weight,  and  dragging  in  the 
pelvis;  pain  in  the  back,  groins,  and  thighs;  burning  and  pricking  in  the 
vagina,  and  vesical  and  rectal  tenesmus.  After  four  or  five  days  there  is 
usually  a  discharge  of  a  viscid  liquid,  which  in  eight  or  ten  days  becomes 
creamy,  purulent,  and  perhaps  bloody;  tympanites  and  sensitiveness  upon 
pressure,  and  uterine  tenesmus  or  "bearing-down  pains,"  show  themselves 
in  severe  cases,  and  at  times,  though  rarely,  there  is  active  diarrhoea  due 
to  reflex  irritation  of  the  rectal  nerves.  Should  the  fluid  discharged  from 
the  vagina  be  allowed  to  come  in  contact  with  the  skin  of  the  vulva,  abdo- 
men, or  thighs,  an  intense  cutaneous  irritation  is  established,  which  may 
go  on  to  excoriation  and  the  development  of  pruritus  of  aggravated  char- 
acter. In  two  cases  I  have  seen  prurigo  thus  excited  which  spread  over 
the  entire  body.  If  the  reaction  of  this  purulent  discharge  be  examined 
into,  it  will  sometimes  be  found  to  be  acid  and  at  other  times  alkaline. 
The  explanation  of  the  fact  is  this :  the  discharge  from  the  uterus  is  alka- 
line and  that  from  the  vagina  acid.  If  the  irritating  uterine  fluid  have 
established,  as  it  very  generally  does,  vaginitis,  the  acid  secretion  from 
this  source  overcomes  the  alkalinity  of  that  from  the  other.  If,  on  the 
other  hand,  no  severe  vaginitis  exist,  the  discharge  from  the  uterus  pre- 
sents its  ordinary  alkaline  features. 

Physical  Signs Upon   examination  by  touch  the  os  uteri   is  found 

gaping,  the  cervix  swollen  and  very  sensitive  to  pressure,  the  body  slightly 
enlarged,  and  the  whole  organ  lower  than  normal  in  the  pelvis.  Through 
the  speculum  the  cervix  is  found  to  look  swollen,  oedematous,  and  red, 
and  from  the  pouting  os  pours  forth  either  a  clear,  albuminous-looking 
fluid,  muco-pus,  or  long  tenacious  shreds  of  cervical  mucus.  All  explora- 
tions of  the  uterus  should,  as  a  rule,  be  avoided.     The  probe,  if  used  at 


DIFFERENTIATION PATHOLOGY.  271 

all,  should  be  employed  with  the  greatest  caution,  and  never  unless  passed 
through  the  speculum.  The  sound  as  ordinarily  used  should  not  be 
thought  of.  Probing  will  discover  great  sensitiveness  throughout  the 
uterine  cavity,  and  the  slightest  touch  upon  the  fundus  will  cause  the 
discharge  of  a  few  drops  of  blood.  Indeed,  so  great  is  the  engorgement 
that  even  the  introduction  of  the  speculum  will  often  cause  blood  to  flow 
from  the  cervix. 

Bimanual  examination  will  discover  the  uterine  body  enlarged,  and 
tender  upon  pressure,  so  that  one  who  judged  hastily,  and  without  suffi- 
cient knowledge  of  the  subject,  would  be  very  apt  to  diagnosticate  with 
great  positiveness  acute  parenchymatous  metritis.  There  can  be  no  doubt 
that  many  of  the  reported  cases  of  that  affection  have  been  nothing  more 
than  instances  of  this  form  of  endometritis. 

Differentiation. — The  only  diseases  with  which  this  would  with  any 
probability  be  confounded  are,  periuterine  cellulitis,  pelvic  peritonitis,  and 
acute  vaginitis.  In  the  first  two  of  these,  constitutional  disturbance  is 
generally  more  marked  and  excessive  than  in  this ;  they  are  often  pre- 
ceded by  chill,  and  usually  by  more  intense  febrile  action,  and  greater 
elevation  of  temperature.  This,  however,  is  not  universally  true.  The 
last  is  very  generally  attended  by  a  lesser  degree  of  general  disturbance. 
No  positive  conclusion  can  usually  be  arrived  at  without  physical  explo- 
ration, which  in  pelvic  inflammation  will  discover  fixation  of  the  uterus, 
hardening  of  periuterine  tissue,  and  excessive  tenderness  when  parts  other 
than  the  uterus  are  compressed  by  conjoined  manipulation.  It  will 
generally  be  noticed  that  in  cellulitis  and  peritonitis  there  is  no  great 
increase  of  uterine  or  vaginal  discharge. 

Pathology In  its  first  stage  acute  endometritis  consists  in  an  intense 

and  active  hyperemia  of  the  mucous  lining  of  the  uterus,  which  is  red, 
swollen,  oedematous,  and  softened.  Its  surface  is  spotted,  Scanzoni  de- 
clares, from  congestion  of  the  capillary  network  around  the  mouths  of  the 
utricular  follicles.  When  the  second  stage  has  set  in,  the  cavity  of  the 
uterus  is  found  to  contain  an  excess  of  mucus  or  creamy-looking  pus, 
which  may  be  more  or  less  mingled  with  blood.  If  the  cervix  be  involved 
in  this  inflammatory  engorgement,  the  mucous  membrane  of  its  vaginal 
portion  participates  markedly,  as  an  examination  by  the  speculum  will 
prove. 

In  the  mucus  just  mentioned  the  microscope  reveals  the  presence  of 
thousands  of  cells  and  sometimes  entire  casts  of  the  utricular  follicles. 

"  Ordinarily,"  says  Scanzoni,1  "  acute  catarrh  of  the  mucous  membrane 
of  the  uterus  is  accompanied  by  a  congestive  swelling  of  the  muscular 
substance  of  the  womb,  and  most  generally  it  is  possible,  particularly  in 
the  most  internal  layers  of  the  organ,  to  see  with  the  naked  eye,  that  the 

1  Diseases  of  Females,  American  ed.,  p.  193. 


272  ACUTE    ENDOMETRITIS. 

vessels  are  gorged  with  blood.  There  ordinarily  result  from  it  an  infiltra- 
tion and  a  softening,  which  are  much  greater  in  the  layers  of  the  paren- 
chyma of  the  uterus  nearest  to  the  mucous  membrane.  Hence,  these 
alterations  of  tissue  which  are  characteristic  of  acute  parenchymatous 
metritis  ordinarily  accompany  catarrh  of  the  mucous  membrane,  when 
this  has  attained  a  high  degree  of  intensity."  "  The  whole  substance  of 
the  uterus,"  says  Klob,1  "  generally  appears  to  be  increased,  and  its  tissue 
more  vascular  and  succulent,  especially  in  the  layers  nearest  the  mucous 
membrane." 

Acute  endometritis  very  rarely  shows  itself  before  puberty. 

Complications. — Its  complications  are  acute  metritis,  urethritis,  vagi- 
nitis, vulvitis,  cystitis,  salpingitis,  pelvic  peritonitis,  and  various  eruptive 
disorders,  the  results  of  scratching  excited  by  pruritus  vulvae. 

The  first  of  these  complicating  conditions  is  of  so  much  moment  as  to 
require  special  consideration. 

The  time  has,  I  think,  arrived  when,  with  our  present  light  upon  the 
subject,  acute  parenchymatous  metritis  should  be  given  a  subordinate 
place  in  pathology  instead  of  the  prominent  one  which  it  formerly  occu- 
pied. With  reference  to  its  frequency  as  a  primary  affection,  many  con- 
flicting statements  will  be  found.  This  arises  partly  from  the  fact  that 
some  liave  written  of  it  without  making  any  distinction  between  the  forms 
occurring  in  the  puerperal  and  non-puerperal  states,  while  others  have 
confined  their  remarks,  as  is  here  done,  to  the  disease  in  the  latter  condi- 
tion ;  partly  from  endometritis,  active  congestion  from  suppressio  mensium, 
and  peritonitis  and  cellulitis  having  been  mistaken  for  metritis  ;  and  in 
great  part  from  the  difficulty  of  gaining  post-mortem  evidence,  the  disease 
generally  being  recovered  from.  As  a  complication  of  inflammation  of 
the  internal  mucous  or  external  serous  covering  of  the  uterus,  parenchy- 
matous inflammation  is  universally  admitted.  As  a  pathological  entity, 
however,  I  question  whether  any  well-authenticated  case  of  this  affection 
is  on  record.  The  descriptions  of  the  disease  which  are  given  in  recent 
works,  such,  for  example,  as  those  of  Courty,  Gallard,  and  Scanzoni, 
each  of  whom  devotes  considerable  space  to  it,  appear  to  me  to  have 
come  down  to  us  as  a  matter  of  literary  tradition  rather  than  of  clinical 
research. 

While  searching  for  a  case  of  pure  uncomplicated  metritis,  I  have  seen 
numbers  of  cases  which  were  regarded  by  others  as  of  this  character,  and 
quite  a  number  which  I  viewed  as  such  until  enlightened  by  post-mortem 
or  other  evidence.  Kokitansky2  declares  that,  "  in  acute  inflammation  of 
this  organ,  generally  the  lining  membrane  of  the  uterus  is  affected  pri- 
marily, and  that  this   is  scarcely  ever  the  case  with  the  uterine  tissue,  as 

1  Path.  Anat.  Female  Sec.  Organs,  American  ed.,  p.  231. 

2  Pathology  Anat. 


TREATMENT.  273 

far  as  can  be  demonstrated  by  the  pathological  anatomist,  with  the  ex- 
ception of  the  reaction  following  traumatic  influences,  especially  of  the 
vaginal  portion." 

In  his  recent  work  Klob1  takes  still  stronger  ground  as  to  the  existence 
of  uncomplicated  metritis,  and  asserts  that  never  having  met  with  an 
instance  of  the  disease,  he  is  forced  to  describe  it  upon  the  authority  of 
others. 

Some  practitioners  are  prone  to  regard  every  case  of  inflammatory 
action  in  the  pelvis,  accompanied  by  great  tenderness  over  the  uterus,  as 
metritis.  Such  cases  are  much  more  frequently  due  to  pelvic  cellulitis  or 
peritonitis,  which  are  by  no  means  rare  affections,  or  to  active  congestion, 
caused  by  suppression  of  the  menses  or  excessive  coition.  After  parturi- 
tion, either  at  term  or  premature,  true  metritis  does  occur  not  unfrequently, 
but  this  variety  does  not  concern  our  present  investigation.  As  regards 
that  form  which  we  are  considering,  I  feel  convinced  that,  if  the  expe- 
rienced practitioner  will  put  aside  his  preconceived  views  and  interrogate 
the  results  of  his  observation,  he  will  find,  if  he  has  his  attention  aroused 
to  the  frequency  of  the  diseases  which  simulate  it,  that  he  has  met  with 
this  affection  very  rarely. 

Course,  Duration,  and  Termination Acute  endometritis,  when  oc- 
curring in  the  non-puerperal  state,  may,  without  treatment  even,  go  on  to 
recovery,  generally  lasting  from  a  month  to  six  weeks,  and  perhaps  pass- 
ing through  its  whole  course  without  its  existence  having  been  diagnosti- 
cated. It  sometimes  ends  in  the  chronic  form  of  mucous  inflammation,  or 
even  in  slight  hyperplasia,  the  superficial,  subjacent,  connective  tissue  be- 
coming affected.  It  is  doubtful  whether  any  severe  case  of  endometritis 
runs  its  course  without  being  to  a  greater  or  less  extent  complicated  by  a 
slight  degree  of  parenchymatous  disorder.  As  already  stated,  the  disease 
may  end  in  chronic  endometritis  or  in  recovery.  It  may,  likewise,  end 
in  death  ;  inflammatory  action  spreading  along  the  Fallopian  tubes  and 
causing  salpingitis,  which,  by  resulting  in  free  purulent  discharge  into  the 
peritoneum,  may  establish  inflammation  there. 

Prognosis — In  spite  of  all  these  possibilities  the  prognosis  is  always 
favorable  if  the  patient  take  ordinary  care  of  herself  and  yield  to  a  judi- 
cious plan  of  treatment. 

Treatment — The  diagnosis  having  been  clearly  made,  treatment  should 
be  at  once  established.  Complete  rest  of  mind  and  body  should  be  re- 
garded as  essential  points.  In  severe  cases,  the  patient  should  be  kept 
perfectly  quiet  upon  her  back  in  bed,  and  not  allowed  to  leave  it  or  to 
assume  the  sitting  posture  even  to  satisfy  the  calls  of  nature.  Opium 
should  be  freely  given  by  mouth  or  rectum  for  the  production  of  perfect 
nervous  quiescence  and  for  the  relief  of  pain.     In  severe  cases  one  grain 

1  Path.  Anat.  Female  Sex.  Organs,  American  ed.,  p.  231. 

18 


274  ACUTE    ENDOMETRITIS. 

of  powdered  opium  or  its  equivalent  of  morphia  should  be  administered 
every  third  hour.  This  drug,  I  feel  sure,  not  only  acts  as  a  sedative  to 
the  nervous  system,  and  a  quieter  of  pain ;  it  absolutely  modifies  the  in- 
flammatory process  by  its  influence  upon  the  nerves.  The  bowels,  unless 
constipation  exists,  should  not  be  acted  upon  by  cathartics,  and  ordinarily 
no  other  medicine  than  opium  should  be  administered.  Over  the  hypo- 
gastrium  a  soft,  warm  poultice  of  powdered  linseed  should  be  placed  and 
covered  by  oiled  silk.  This  need  not  be  renewed  oftener  than  once  in 
twelve  hours,  for  the  oiled  silk  will  preserve  its  warmth.  The  patient 
should  not  be  annoyed  by  leeches  or  cups.  Even  if  high  febrile  action 
show  itself,  this  can  be  readily  controlled  by  appropriate  administration 
of  tincture  of  veratrum  viride.  The  diet  should  be  very  simple,  and 
should  consist  of  fluid  food  chiefly,  as  milk,  beef-tea,  etc.  A  condition 
of  intestinal  quietude  should  be  encouraged,  and  therefore  such  food  as 
involves  the  elimination  of  a  small  amount  of  excrementitious  matter 
should  be  allowed.  By  these  means  motion  in  the  abdominal  cavity  may 
be  lessened,  and  rest  be  assured  to  the  diseased  part.  As  soon  as  free 
secretion  of  muco-pus  begins  to  show  itself,  the  vagina  should  be  gently 
syringed  out  three  times  daily  with  copious  injections  of  very  warm  water. 
For  the  proper  accomplishment  of  this  the  patient  should  turn  so  as  to 
lie  across  the  bed,  in  the  French  obstetric  position,  on  the  back,  with  the 
buttocks  over  the  edge  of  the  bed,  which  has  been  protected  by  India- 
rubber  cloth,  each  foot  being  supported  by  a  chair.  A  nurse,  then  placing 
between  the  thighs  a  tub  containing  three  or  four  gallons  of  water,  should 
pass  the  nozzle  of  a  Davidson's  syringe  up  to  the  cervix,  and  for  fifteen 
minutes  project  against  it  a  steady  stream.  All  examination  by  speculum, 
probe,  and,  after  a  diagnosis  has  been  made,  even  by  the  finger,  should 
be  avoided  unless  some  special  indication  demand  it.  Astringent  injec- 
tions and  all  vaginal  applications  should  be  avoided.  The  affection  which 
we  are  treating  is  located  in  the  uterus,  not  in  the  vagina,  and  such  appli- 
cations merely  annoy  the  patient  and  aggravate  the  disease.  The  warm 
injections  which  have  been  advised  act  as  poultices  or  fomentations  to  the 
whole  internal  surface  of  the  pelvis,  at  the  same  time  that  tliey  insure 
cleanliness  to  the  vagina  and  remove  from  it  a  fluid  which,  if  left  there, 
might  excite  vaginitis.  Under  this  plan  of  treatment  the  patient  should 
be  kept  until  recovery,  or  until  we  are  admonished  by  time  that  the  dis- 
<  ;i-"  has  passed  into  its  chronic  form  and  requires  different  remedies. 

To  one  accustomed  to  the  advice  to  apply  leeches  to  the  cervix  or  peri- 
neum, pass  the  speculum,  and  apply  solid  nitrate  of  silver  to  the  cervical 
canal,  inject  the  vagina  with  solutions  of  persulphate  of  iron,  keep  the 
bowels  constantly  active  by  saline  cathartics,  etc.,  this  plan  may  appear 
too  inefficient  to  be  relied  upon.  Of  any  one  entertaining  this  doubt  I 
would  ask  a  trial  and  comparison  of  the  two  methods  before  he  arrives  at 
a  decision  which  will  jruide  his  future  practice.  If  his  experience  agree 
with  mine,  I  do  not  doubt  the  resulting  verdict. 


CHRONIC    CERVICAL    ENDOMETRITIS, 


275 


CHAPTER  XVIII. 

CHRONIC  CERVICAL  ENDOMETRITIS. 

When  inflammation  of  acute  character  affects  the  uterus,  it  has  a  marked 
tendency  to  invade  the  entire  organ,  and  to  involve  both  cervix  and  body 
but  with  chronic  inflammation  this  is  not  the  case.  Being  of  a  lower 
grade  of  intensity,  it  more  strictly  confines  itself  to  the  mucous  mem- 
brane and  limits  itself  to  the  body  or  cervix.  Such  limitation  is,  how- 
ever, neither  universal  nor  absolute,  sometimes  subjacent  parts  being 
more  or  less  implicated,  and  at  others  the  mucous  membrane  of  the  entire 
organ  being  simultaneously  and  equally  involved. 

Definition — By  the  term  chronic  cervical  endometritis  is  meant  chronic 
inflammation  of  the  mucous  membrane,  extending  from  the  os  internum 
to  the  os  externum,  as  represented  by  the  dots  in  Fig.  110. 

Fig.  110. 


The  dots  represent  the  site  of  chronic  cervical  endometritis. 


Frequency Of  all  diseases  of  the  genital  system  of  the  female  this  is 

without  doubt  the  most  frequent,  and,  although  not  in  itself  a  malady  of 
dangerous  character,  may  prove  the  starting  point  for  some  of  the  most 
serious  and  rebellious  of  uterine  disorders.     Exposed  as  the  cervix  uteri 


276 


CHRONIC    CERVICAL    ENDOMETRITIS. 


is  to  injury  during  coition,  laceration  from  parturition,  and  irritation  from 
walking,  riding,  and  lifting,  it  is  not  surprising  that  its  complicated  in- 
vestment should  frequently  become  the  seat  of  disease. 

This  affection  too  is  a  frequent  source  of  menstrual  disorders,  and  very 
commonly  produces  sterility. 

Synonyms It  has  been  described  under  the  names  of  cervical  catarrh, 

cervical  leucorrhoea,  and  endo-cervicitis. 

Anatomy  of  the  Cervical  Mucous  Membrane — The  cavity  of  the  cervix 
uteri  is  a  fusiform  canal,  measuring  about  one  inch  and  a  quarter,  begin- 
ning at  the  os  internum  above  and  ending  at  the  os  externum  below.  On 
the  anterior  and  posterior  walls  of  the  cervix  are  ridges,  from  which  folds 
are  given  off  which  are  arranged  with  regularity,  and  run  obliquely  up- 
wards and  outwards,  to  end  in  other  indistinct  lines  on  the  sides  of  the 
canal.  This  arrangement  of  mucous  membrane  has  received  the  name  of 
arbor  vitie. 

Between  these  folds  numerous  mucous  glands  are  seen,  which  are  called 
by  some  the  glands  of  Naboth.1     Dr.  Tyler  Smith2  estimates  that  a  well- 

Fig.  111. 


Villi  of  canal  of  the  corvix  nteri,  covered  by  cylindrical  epithelium  and  containing  looped 
bloodvessels.     One  hundred  diameters.     (T.  Smith.) 

developed  virgin  cervix  probably  contains  at  least  ten  thousand  of  these 
follicles.     The  mucous  membrane  forming  these  folds  or  rugae  is  covered 


1  A  great  deal  of  curiosity  attaches  to  the  nature  and  function  of  these  glands. 
Somo  regard  the  Nabothian  glands  as  identical  with  the  muciparous  follicles,  others 
look  upon  them  as  occluded  glands  distended  by  their  retained  secretion. 

2  On  Leucorrhoea,  Am.  ed.,  p.  38. 


PREDISPOSING    CAUSES.  277 

over  by  cylindrical  and  ciliated  epithelium  and  studded  by  villi,  which  are 
found  in  considerable  numbers  upon  the  larger  ruga;  and  other  parts  of  the 
mucous  membrane.     (Fig.  111.) 

The  natural  secretion  of  the  cervical  canal  has  been  shown  by  M.  Donne 
to  be  alkaline,  unlike  that  of  the  vagina,  which  is  acid. 

Patlioloyy. — Cervical  endometritis  consists  in  inflammation  of  all  this 
structure  and  consequent  alteration  of  its  condition.  The  mucous  glands 
are  especially  involved  in  the  morbid  action,  the  disease  chiefly  consisting 
in  glandular  inflammation.  The  glairy  mucus  which  is  secreted  in  large 
amount  as  one  of  its  symptoms  is  the  characteristic  discharge  of  these  struc- 
tures. Looked  at  with  a  strong  glass  in  post-mortem  examinations  of  this 
disease,  they  are  seen  enlarged  and  elevated,  and,  according  to  Aran,1  their 
mouths  may  be  seen  very  much  dilated.  In  some  cases  it  becomes  com- 
plicated by  granular  degeneration.  The  villi  or  papilla;,  especially  those 
on  the  vaginal  face  of  the  cervix,  become  diseased.  At  first  there  is  a 
loss  of  the  normal  supply  of  epithelium,  which  produces  a  slight  and  very 
superficial  abrasion.  This  becomes  in  time  more  distinct  and  marked, 
from  destruction  of  the  villi  themselves  over  spaces  of  greater  or  less  ex- 
tent. If  this  process  of  destruction  should  go  on  and  affect  the  deeper  tis- 
sues, a  true  ulcer  would  be  formed,  and  no  one  would  ever  have  denied  the 
name  of  ulceration  to  the  existing  condition,  but  it  does  not  thus  progress. 
In  time  an  hypertrophy  occurs  in  the  villi,  which  increase  in  size,  project 
like  so  many  hairs  from  the  surface,  and  give  to  the  os  and  cervix  an  ap- 
pearance which  has  caused  the  term  granular  degeneration  to  be  applied 
to  it.  This  state  affects  the  vaginal  portion  of  the  cervix  chiefly,  but  may 
extend  up  the  canal. 

Another  pathological  state,  which  is  occasionally  met  with  as  a  compli- 
cation of  cervical  endometritis,  is  an  eversion  of  the  os  and  lower  portion 
of  the  canal  to  such  an  extent  as  to  keep  up  inflammation  there  by  the 
friction  of  the  membrane,  thus  exposed,  against  the  floor  of  the  pelvis. 
Some  very  obstinate  cases  are  due  to  this  condition. 

The  diseased  mucous  membrane  pours  forth  with  great  activity  large 
amounts  of  thick,  tenacious  mucus,  which  is  loaded  with  epithelium  and 
sometimes  tinged  with  blood. 

Predisposing  Causes. — It  is  a  matter  of  some  moment  that  the  etiology 
of  this  affection  should  be  studied  under  two  heads — predisposing  and  ex- 
citing.    The  former  includes  : — 

Natural  feebleness  of  constitution  ; 

The  existence  of  a  cachexia,  as  tuberculosis  or  scrofula ; 

Impoverishment  of  the  blood  from  chlorosis  or  other  cause ; 

Prolonged  mental  depression  ; 

Insufficient  nutriment ; 

»  Mai.  de  l'Uterus,  p.  423. 


278  CHRONIC    CERVICAL    ENDOMETRITIS. 

Excessive  lactation  ; 
Frequent  parturition  ; 
Subinvolution  ; 

Styles  of  dress  which  depress  the  uterus ; 
Want  of  exercise  and  fresh  air. 
These  influences  either  act  injuriously  upon  the  nervous  system,  and 
thus  interfere  with  the  circulation  and  nutrition  of  the  lining  membrane  of 
the  cervix  ;  or  by  directly  disordering  the  vessels  and  nerves  of  the  uterus 
render  it  ready  for  the  establishment  of  disease  by  some  cause  which  would 
have  exerted  no  baneful  effect  upon  a  woman  in  perfect  health. 

It  may  naturally  be  asked  why  some  of  these  influences  should  especially 
produce  this  disease.  My  answer  is,  that  they  do  not  do  so.  Sometimes 
they  cause  chronic  pneumonia  ;  at  other  times  granular  eyelids  ;  at  others 
follicular  faucitis  ;  and  again  at  others  chronic  cervical  endometritis. 

Exciting  Causes Chief  among  these  may  be  enumerated  : — 

Displacements  of  the  uterus,  especially  flexions  ; 
Excessive  or  intemperate  coition  ; 
The  use  of  intra-uterine  pessaries  ; 
Puerperal  endometritis  ; 
Acute  non-puerperal  endometritis ; 
Exposure  or  fatigue  affecting  a  subinvoluted  uterus ; 
Efforts  at  production  of  abortion  and  prevention  of  conception  ; 
Vaginitis,  specific  or  simple  ; 
Obstructive  dysmenorrhea ; 
Cervical  polypi ; 
Laceration  of  the  cervix. 
Many  other  causes  might  be  enumerated  ;  but  these  will  suffice  to  show 
the   nature  of   those   influences   which   act   as  excitants  of  the  disease. 
Many  of  those  mentioned  would  fail  to  produce  it  in  a  uterus  which  had 
not  been  prepared  for  their  action  by  depreciating  constitutional  condi- 
tions.    "When  treatment  is  established  for  the  cure  of  the  disease,  if  it  be 
inaugurated  and  pursued  without  regard  to  the  predisposing  causes,  it  will 
often  prove  inefficient  or  futile  in  cases  which  would  yield  to  a  plan  that 
showed  a  recognition  of  their  importance.     Appreciating  highly,  as  I  do, 
the  value  of  local  treatment  in  uterine  affections,  were  I  in  the  manage- 
ment of   the  disease  limited  entirely  to  one  kind — local  or  general — I  do 
not  hesitate  to  say  that  I  would  infinitely  prefer  the  latter.     A  removal 
from  a  city  to  the  country,  the  use  of  mineral  and  vegetable  tonics,  plenty 
of  good,  nutritious  food,  the  observance  of  regular  hours,  the  systematic 
practice  of  exercise  in  the  fresh  air,  and  the  pleasures  of  cheerful  society, 
will,  I  feel  confident,  do  far  more  for  the   patient  than  a  weekly  visit  to 
the  office  of  a  physician  and   the  reception  of  the  most  appropriate  local 
treatment  which  science  can  afford.     But  better  than  either  plan  is  the 
judicious  combination  of  the  two.     They  should  go  hand  in  hand.     My 


PHYSICAL    SIGNS.  279 

wish  is  to  keep  prominent  the  fact,  that  of  the  two  the  general  treatment 
is  the  more  important  in  the  disease  which  now  concerns  us,  as  it  is  in 
many  others  which  we  shall  come  to  consider. 

Symptoms Cervical  endometritis  may  exist  for  a  length  of  time  with- 
out presenting  any  symptoms  of  sufficient  gravity  to  warn  the  patient  of 
its  presence.  Even  a  leucorrhoea,  which  is  somewhat  abundant,  often 
fails  to  attract  her  attention.  The  answer  to  a  question  as  to  its  existence 
will  often  be  a  negative  one  in  cases  in  which  the  practitioner  will,  by 
the  speculum,  discover  a  considerable  amount  in  the  vagina.  In  the 
great  majority  of  cases  She  disease  will  soon  announce  its  existence  by 
some  or  all  of  the  following  signs.  The  first  symptom  which  will  attract 
attention  will  probably  be  dragging  sensations  about  the  pelvis.  These 
will  soon  be  followed  by  pain  in  the  back  and  loins,  which  will  be  very 
much  increased  by  exercise  or  muscular  efforts.  Then  a  more  or  less  pro- 
fuse leucorrhoea  will  be  noticed,  the  discharge  as  it  issues  from  the  vulva 
resembling  boiled  starch  or  thick  gum-water,  and  often  irritating  the 
vulva  and  vagina  to  such  an  extent  as  to  produce  inflammation  in  them. 
Menstrual  disorders  may  now  show  themselves.  The  discharge  may  be 
either  too  scanty  or  too  profuse,  too  frequent  or  too  infrequent,  and  to  a 
certain  extent  painful ;  sometimes,  though  not  often,  decided  dysmenor- 
rhea will  exist. 

Usually  before  the  disease  has  existed  for  a  long  period,  the  constitution 
of  the  patient  will  show  signs  of  becoming  implicated.  She  will  become 
nervous,  irascible,  moody,  and  often  hysterical.  Her  appetite  will  dimin- 
ish and  digestion  grow  feeble,  so  that  impoverished  blood  will  soon  be 
observed  as  a  result  of  impaired  nutrition.  With  some  or  all  of  these 
signs  of  the  existing  disorder,  the  patient  may  continue  for  a  length  of 
time  without  suffering  from  others  of  more  annoying  or  graver  character. 
Complications  may,  however,  rapidly  develop  themselves ;  cystitis,  cervi- 
cal hyperplasia,  and  vaginitis  coming  on  and  proving  exceedingly  trouble- 
some. At  times  pain  during  sexual  intercourse  constitutes  a  prominent 
sign  of  cervical  disease,  but  it  belongs  rather  to  cervical  hyperplasia  than 
to  endometritis,  the  former  having  added  itself  as  a  complication  to  the 
latter,  and  thus  produced  the  symptom.  Sometimes  nausea,  and  even 
vomiting,  present  themselves  as  symptoms,  and  these,  together  with  the 
digestive  disorder  before  mentioned,  produce  a  deterioration  in  the  nutri- 
tion of  the  patient. 

Although  these  symptoms  are  enough  to  make  us  confident  of  the  ex- 
istence of  uterine  disorder,  they  by  no  means  furnish  reliable  grounds  for 
a  positive  diagnosis.     This  can  be  arrived  at  only  by  physical  exploration. 

Physical  Signs The  patient  being  placed  upon  her  back,  and   the 

finger  of  the  examiner  introduced  into  the  vagina,  the  os  uteri  will  pro- 
bably be  found  in  its  usual  position  in  the  pelvis,  for  the  weight  of  the 
uterus  is  not  increased,  the  connective  tissue  not  being  involved.     The  os 


280  CHRONIC    CERVICAL    ENDOMETRITIS. 

may  be  somewhat  enlarged  and  its  lips  slightly  puffed,  or  it  may  be 
roughened  on  account  of  granular  degeneration.  Sometimes,  however, 
severe  cervical  endometritis  may  exist  without  any  enlargement  of  the  os, 
or  any  trace  of  abrasion  or  granular  degeneration.  If  the  finger  be  placed 
under  the  cervix  and  that  part  raised  by  it,  pain  will  be  complained  of, 
though  not  to  any  great  extent.  This  will  be  most  marked  opposite  the 
os  internum.  No  other  affirmative  sign  can  be  elicited  by  this  means,  and 
the  speculum  should  then  be  used.  By  this  the  os  will  be  seen  to  be  in 
the  condition  just  described,  and  from  it  will  be  found  to  exude  a  long 
string  of  tough,  tenacious  mucus  which  will  closely  resemble  the  white  of 
egg.  If  entangled  by  a  small  mass  of  cotton  attached  to  the  end  of  a 
whalebone  rod,  it  will  be  found  to  be  so  viscid  and  resisting  that  it  cannot 
be  drawn  from  the  canal.  It  will  resist  even  a  stream  of  water  thrown 
with  some  force  upon  it,  and  very  often  is  removed  only  after  several 
efforts  by  this  or  other  means.  The  cervix  will  usually  be  found  to  be 
somewhat  enlarged.  Its  tissue  may  present  a  swollen,  puffed  appearance, 
or  be  intensely  red  as  if  in  a  state  of  granular  degeneration,  which  will 
upon  close  inspection  be  found  to  be  due  to  removal  of  its  investing  epithe- 
lium and  the  occurrence  of  hypertrophy  of  the  villi.  Should  this  condi- 
tion exist,  it  will  afford  relief  to  the  mind  of  the  inexperienced  gynecolo- 
gist, for  the  diagnosis  of  the  case  will  be  clear.  But  another  state  of 
things  may  be  discovered  which  will  leave  him  in  doubt.  Upon  removing 
the  plug  of  obstructing  mucus,  he  may  discover  no  evidence  of  disease. 
The  os  is  no  larger  than  it  should  be,  its  tissue  is  not  reddened,  no  degene- 
ration exists,  in  fact  nothing  is  found  explaining  the  backache,  nervous- 
ness, impaired  nutrition,  and  profuse  leucorrhoea  which  led  him  to  advise 
and  urge  the  examination.  The  case  is  simply  one  of  cervical  endome- 
tritis which  affects  the  glands  of  the  canal  without  having  produced  granu- 
lar degeneration. 

It  is  often  a  matter  of  great  difficulty  to  decide  whether  endometritis  is 
confined  to  the  neck  or  extends  through  this  part  into  the  body.  In  many 
cases  a  certain  conclusion  is  impossible.  The  evidences  by  which  it  may 
be  usually  arrived  at  are  these  :  in  the  former  case  the  neck  alone  is  found 
enlarged  and  lender  to  touch,  conjoined  manipulation,  and  the  probe ;  in 
the  latter,  the  body  also  shows  these  signs  of  implication  of  ils  tissues  in 
the  morbid  action.  The  discharge  resulting  in  the  former  is  more  thick, 
tenacious,  and  difficult  of  removal  than  in  the  latter  variety.  Lastly,  the 
constitutional  symptoms  attending  the  latter  are  ordinarily  graver  than 
those  created  by  the  former. 

Course,  Duration,  and  Termination. — Cervical  endometritis  is  not  a 
self-limitin<r  disease,  and  consequently  its  duration  will  depend  upon  circum- 
stances which  control  its  progress.  It  may  unquestionably  disappear  with- 
out medical  aid.  Any  alterative  influence  which  exerts  a  complete  change 
in  the  economy,  as,  for  instance,  parturition,  entire  alteration  of  the  habits 


TREATMENT.  281 

of  life,  or  some  change  equally  decided,  sometimes  results  in  a  cure.  But 
it  is  certainly  safe  to  say  that,  unchecked,  it  frequently  passes,  in  multi- 
parous  women,  into  cervical  hyperplasia,  which  would  probably  draw  in 
its  train  displacement,  and  all  the  long  list  of  ailments  which  make  the 
lives  of  women  suffering  from  uterine  disease  so  burdensome. 

Prognosis The  prognosis  of  this  affection  will  depend  upon  the  degree 

of  glandular  disease  accompanying  it.  If  the  mucus  which  marks  inflam- 
mation of  the  glands  be  slight  in  amount,  and  not  very  tenacious  in  cha- 
racter, whatever  be  the  extent  of  coincident  granular  degeneration,  the 
prognosis  is  favorable.  When,  on  the  other  hand,  there  is  little  granular 
disease,  and  a  large  amount  of  thick,  resisting  mucus  hangs  from  the  cer- 
vical canal,  the  prognosis,  according  to  my  experience,  is  very  doubtful, 
and  sometimes  hopeless,  unless  very  radical  measures  be  adopted.  If 
every  practitioner  will  look  back  into  his  experience,  he  will  see  that  in 
all  severe  cases  he  has  either  been  forced  to  resort,  for  their  cure,  to 
measures  which  absolutely  destroy  the  diseased  glands,  or  that  the  patients 
in  time,  wearied  of  his  insuccess,  have  gone  for  treatment  elsewhere.  Let 
it  be  remembered  that  I  allude  now  only  to  very  severe  cases  where  the 
glands  are  profoundly  involved.  In  regard  to  such,  I  feel  sure  that  the 
experience  of  others  must  agree  with  mine. 

Even  in  minor  cases  great  caution  should  be  observed  as  to  fixing  the 
time  at  which  recovery  will  take  place.  Even  in  the  mildest  case  which 
has  lasted  for  some  time,  from  four  to  six  months  will  probably  elapse 
before  perfect  cure  can  be  accomplished,  and  even  after  this  a  relapse  will 
be  very  likely  to  occur  unless  preventive  measures  be  adopted  and  strictly 
adhered  to. 

Treatment The  disease  consisting  in  cervical  endometritis,  the  efforts 

of  the  practitioner  should  be  directed  to  producing  an  alterative  influence 
upon  a  mucous  membrane  which  is  in  a  condition  of  chronic  inflammation, 
and  the  avoidance  of  all  influences  which  may  cause  it  to  spread  to  adja- 
cent tissues.  These  ends  will  be  best  accomplished  by  the  following 
means : — 

General  regimen ; 

Emollient  applications ; 

Alterative  applications; 

Ablation  or  destruction  of  the  diseased  glands. 

General  Regimen "  The  first  care  of  the  practitioner,"  says  Sir  Charles 

Clarke,  "should  be  to  remove,  if  possible,  the  causes  of  the  disease.  .  . 
Women  who  live  in  a  moist  atmosphere,  who  keep  bad  hours,  who  spend 
much  of  their  time  in  bed,  or  who  inhabit  hot  rooms  (being  generally 
weak  women,  and  having  a  relaxed  vagina),  will  be  apt  to  be  affected  by 
the  complaint."  All  such  unfavorable  circumstances  should  be  modified. 
If  any  depressing  influence,  such  as  lactation,  any  habitual  discharge,  or 


282  CHRONIC    CERVICAL    ENDOMETRITIS. 

any  cause  for  mental  anxiety,  be  discovered,  it  should  be  carefully  removed, 
and,  the  patient,  unless  absolutely  plethoric,  be  put  upon  the  use  of  vege- 
table tonics,  the  mineral  acids,  and  preparations  of  iron.  The  functions 
of  the  alimentary  canal  should  he  constantly  supervised.  The  diet  should 
be  mild  and  unstimulating,  hut  most  nutritious.  No  system  of  starvation 
should  be  entered  upon,  for  the  tendency  of  the  disease  is  to  the  produc- 
tion of  spanaemia,  and  this  we  should  combat.  A  course  of  full  diet  is,  on 
the  contrary,  often  decidedly  indicated ;  for,  as  I  have  elsewhere  remarked, 
women  commonly  depreciate  the  vital  forces  by  an  unintentional  starva- 
tion. Under  these  circumstances  I  am  often  in  the  habit  of  prescrihing 
the  following  course:  the  patient  is  directed  to  eat  fresh  animal  food, 
eggs,  butter,  wheat,  etc.,  three  times  a  day  at  regular  meal  times.  Then 
between  breakfast  and  the  midday  meal  to  take  either  a  tumbler  of  fresh 
milk,  half  a  tumbler  of  cream,  or  a  teacupful  of  beef- tea,  and  to  repeat  this 
fluid  but  highly  nutritious  repast  between  the  midday  and  evening  meal, 
and  again  when  retiring  at  night.  It  is  surprising  to  see  how  often  pa- 
tients will  rapidly  improve  in  all  their  functions  under  this  course.  The 
digestion  will  improve  and  constipation  disappear  or  become  greatly 
ameliorated,  and  under  the  improvement  in  the  tone  of  the  nervous  system 
sleep  will  become  more  profound  and  refreshing.  All  spices  and  stimu- 
lating condiments  should  be  avoided.  Every  day,  unless  some  special  con- 
traindication exist,  the  patient  should  take  fresh  air  and  exercise,  by 
carriage  or  on  foot  for  a  time,  which  should  be  limited  by  the  circum- 
stances of  the  particular  case.  If  she  should  be  unable  to  do  this  from 
any  cause,  she  should  be  thoroughly  protected,  and  pure  air,  even  in  win- 
ter, be  allowed  to  circulate  freely  in  her  chamber,  all  the  doors  and  win- 
dows of  which  should  be  opened  for  two  or  three  hours  daily.  This  plan, 
which  is  suggested  by  Prof.  Byford,  of  Chicago,  I  have  found  a  most  ex- 
cellent one.  The  bowels  should  be  kept  regular  by  saline  cathartics,  and 
the  skin  in  proper  state  by  occasional  baths.  Care  must  be  observed  not 
to  depreciate  the  strength  by  catharsis,  and,  to  prevent  this,  a  ferruginous 
tonic  may  be  advantageously  combined  with  a  cathartic,  as  in  the  fol- 
lowing mixtures: — 

R.  Magnesiae  sulphatis,  Jij. 
Ferri  sulphatis,  gr.  xvj. 
Acidi  sulphurici  dil.  3J- 
Aquse,  Oj. — M. 
One  ounce  (two  tablespoonfuls)  in  a  tumbler  of  iced  water  every  morning  upon 
rising. 

R.  Sodse  et  potass,  tart.  3U- 

Vini  ferri  amari  (U.  S.  D.),  3;ij. 
Acidi  tartaric!,  5i'j- 
Aqua?,  |xiv. — M. 
One  ounce  in  a  tumbler  of  iced  water  ever  morning  upon  rising. 


EMOLLIENT    APPLICATIONS.  283 

Should  one  draught  not  be  sufficient,  two  or  even  three  may  be  taken 
daily,  for  the  result  will  prove  tonic  and  reparative  as  well  as  cathartic. 

If  much  disturbance  of  the  nervous  system  should  exist,  the  bromide  of 
potassium  in  doses  of  five  to  ten  grains,  three  times  a  day,  will  be  found 
very  useful. 

The  appetite  and  digestion  are  so  often  impaired  that  special  attention 
will  generally  have  to  be  directed  to  alleviation  of  that  collection  of  symp- 
toms which  are  grouped  under  the  head  of  dyspepsia.  The  stomach  sym- 
pathizing with  the  uterus  does  not  perform  its  functions  with  vigor;  the 
gastric  juices  appear  to  be  wanting  or  inefficient,  and  fermentation  of  the 
food  often  takes  the  place  of  digestion.  Under  these  circumstances  I  can 
recommend  from  lengthy  experience  with  it  the  following  digestive 
tonic : — ■ 

I£.  One  rennet,  washed  and  chopped. 
Sherry  wine,  Oj. 
Macerate  for  twelve  days,  then  decant,  filter,  and  add — 
Dilute  nitro-muriatic  acid,  3U- 
Tinct.  of  nux  vomica,  5U- 
Subnitrate  of  bismuth,  5U- 
One  tablespoonful  in  a  quarter  of  a  tumbler  of  water  before  each  meal. 

This  prescription  combines  the  tonic  properties  of  nux  vomica  and  the 
peculiar  alterative  influences  of  bismuth,  with  a  fluid  which  resembles  the 
gastric  juice.  In  many  cases  of  habitual  indigestion  I  have  obtained  from 
it  the  best  results. 

Emollient  Applications. — "The  cervix  should  be  irrigated  every  night 
and  morning,  by  warm  water  thrown  against  it.  To  the  water  may  be 
added  chloride  of  sodium,  glycerine,  boiled  starch,  infusion  of  linseed, 
slippery  elm,  or  tincture  of  opium.  The  irrigation  should  be  so  planned 
as  to  last  for  ten  or  fifteen  minutes  without  fatiguing  the  patient  or  proving 
a  source  of  annoyance  to  her.  The  methods  for  doing  this  are  so  fully 
described  elsewhere  that  they  need  not  be  repeated  here. 

In  many  cases  of  this  affection  of  not  very  aggravated  character,  and 
which  have  not  advanced  to  the  production  of  granular  degeneration  or 
hyperplasia,  if  this  plan  of  general  tonic  treatment  and  soothing  injections 
be  faithfully  carried  out,  all  complaints  will  cease  on  the  part  of  the  patient, 
and  a  cure  be  gradually  effected.  Should  this  result  not  be  attained,  or 
should  the  disease  be  discovered  at  the  first  examination  to  have  pro- 
foundly involved  the  cervical  glands,  resort  must  be  had  to  applications 
to  the  diseased  surface  through  the  speculum. 

In  cases  in  which  the  lining  membrane  of  the  cervix  is  in  a  condition 
of  granular  degeneration,  and  the  mucous  glands  are  very  little  affected, 
cure  can  be  almost  as  readily  accomplished  as  where  the  same  granular 
disease  exists  on  the  vaginal  face  of  this  part.  But  such  cases  will  be 
treated  of  under  the  caption  of  "  Granular  Degeneration  of  the  Cervix  ;" 


284  CIIRONIC    CERVICAL    ENDOMETRITIS. 

they  do  not  properly  come  under  consideration  at  the  same  time  with  the 
more  obstinate  disease  of  the  glands.  To  make  this  statement,  more  clear; 
cervical  endometritis  consists  of  glandular  inflammation,  which  is  some- 
times complicated  by  granular  degeneration.  In  some  cases  the  glands 
are  very  slightly  diseased,  while  the  villi  of  the  canal  are  decidedly  so  ; 
these  come  under  consideration  rather  as  "  Granular  Degeneration," 
which  will  be  treated  of  elsewhere,  than  as  true  endometritis. 

Alterative  Applications. — It  will  be  found  that  cervical  endometritis, 
existing  in  a  canal  the  os  externum  of  which  is  contracted,  will  always 
prove  much  more  difficult  of  cure  than  in  one  where  this  part  is  dilated. 
The  degree  of  dilatation  will  generally  be  found  to  exert  a  marked  influ- 
ence over  the  tractability  of  the  case.  When  then  it  is  discovered  that 
the  disorder  does  not  disappear  under  the  influence  of  time,  and  the  sim- 
ple measures  already  mentioned,  as  one  of  ordinary  catarrh,  it  is  always 
advisable  to  dilate  this  part  before  proceeding  with  more  decided  measures. 
If  this  be  neglected,  and  the  practitioner  satisfy  himself  with  passing 
through  the  constricted  orifice,  nitrate  of  silver,  iodine,  pencils  of  zinc, 
alum,  iron,  etc.,  once  or  twice  a  week,  no  good  whatever  will  result. 
After  months  or  even  years  of  treatment,  he  will  discover  that  the  mild 
means  which  he  has  adopted  have  left  the  disease  uncontrolled  ;  or  that 
the  severe  ones  have  increased  contraction  of  the  os,  which  renders  men- 
struation difficult  and  painful. 

The  best  and  simplest  method  for  overcoming  the  difficulty  is  to  snip 
the  external  fibres  of  the  os  by  scissors  for  an  eighth  of  an  inch,  touch  the 
raw  surfaces  thus  made  with  nitrate  of  silver  or  solution  of  persulphate  of 
iron  to  prevent  union,  and  keep  plugs  of  carbolized  cotton  in  the  canal  for 
a  week.  Should  there  be  any  objections  to  this  procedure,  which  is  pain- 
less, free  from  danger,  and  effectual,  the  same  thing  may  be  imperfectly 
accomplished  by  repeated  dilatation  by  metallic  sounds,  or  by  the  use  of 
a  tent  of  sea-tangle  or  sponge.  The  use  of  a  tent  which  dilates  the  os 
externum,  not  passing  within  the  os  internum,  is  to  a  great  extent  free 
from  the  dangers  attaching  to  those  which  invade  the  body.     The  os  ex- 

Fig.  112.    • 


DAHHOtV  «r  CO. 


Syringe  for  removing  cervical  mucus. 

ternum  having  been  dilated  by  one  of  these  methods,  the  firsr  if  there  be 
no  special  objection  to  it,  so  that  free  escape  of  the  secretion  of  the  muci- 
parous glands  may  occur,  the  canal  must  be  thoroughly  cleansed.  Unless 
this  be  systematically  done  it  will  be  imperfectly  accomplished,  and  the 


ALTERATIVE    APPLICATIONS.  285 

thick,  tenacious  material  will  completely  shield  the  diseased  glands  and 
neutralize  any  chemical  agent  before  it  can  reach  them.  The  most  effi- 
cient means  for  removing  this  plug  is  the  syringe  represented  in  Fig.  1 12. 
It  is  a  syringe  of  hard  rubber,  two  inches  in  circumference,  holding  an 
ounce,  and  so  arranged  as  to  be  worked  with  one  hand,  the  index  and 
middle  lingers  surrounding  the  neck,  and  the  thumb  retracting  the  piston. 
Upon  the  extremity  of  its  long  pipe  is  slipped  a  bit  of  gutta-percha  tubing, 
the  free  portion  of  which  projects  half  an  inch.  This  free  portion  readily 
enters  the  cervix,  and  goes  up  to  the  os  internum.  When  introduced,  the 
piston  is  powerfully  retracted,  the  mucous  plug  is  sucked  in,  and  the  cer- 
vix is  left  entirely  clean. 

Where  the  material  which  covers  the  os  is  purulent  or  starchy,  and 
not  tenacious,  a  stream  of  water  may  be  projected  from  this  syringe  against 
the  cervix,  and  the  whole  be  removed  by  suction  ;  or  this  may  be  done  by 
a  small  pledget  of  carbolized  cotton  wrapped  around  a  staff  of  whalebone, 
hickory,  or  bamboo,  eight  inches  long,  as  thick  as  a  pipe-stem,  and  taper- 
ing toward  its  extremity.  Should  the  first  pledget  become  saturated,  it 
can  readily  be  slipped  from  the  staff  and  another  wrapped  in  its  place,  or 
several  rods  may  be  prepared  and  kept  ready  for  use. 

Fig.  113. 


Rod  eight  or  nine  inches  long,  wrapped  with  cotton. 

When  the  characteristic  plug  of  tenacious  mucus  is  present,  there  are 
but  two  methods  which  entirely  remove  it :  one  is  the  exhausting  syringe  ; 
the  other  the  use  of  a  dry  sponge  as  large  as  a  raspberry  fixed  in  a  long- 
handled  sponge  holder,  or  held  in  long  dressing  forceps  such  as  those 
shown  in  Fig.  2,  and  passed  into  the  cervical  canal  and  rotated  so  as  to 
entangle  the  thick  mucus.  The  sponge  should  be  thrown  away  afterwards, 
for  the  repetition  of  its  use  might  convey  disease  from  one  patient  to 
another.  A  supply  of  such  small  pieces  of  sponge  should  be  kept  at  hand, 
in  order  that  a  new  one  may  be  used  for  each  patient.  After  having 
been  cleansed  by  one  of  these  .methods,  the  cervical  mucous  membrane  is 
exposed,  and  applications  can  be  made  to  it  with  some  prospect  of  their 
coming  in  contact  with  the  diseased  glands  embedded  in  the  jungle  of 
convolutions  which  constitute  the  arbor  vitae.  A  neglect  of  the  syste- 
matic removal  of  this  material,  I  believe  often  prevents  cure,  and  hence 
I  am  so  minute  in  reference  to  what  may  appear  an  insignificant  point. 

It  is  a  fact,  universally  admitted  in  every  department  of  therapeutics, 
that  certain  substances  of  greater  or  less  strength  as  escharotics  have  the 
property,  when  applied  to  inflamed  mucous  surfaces,  of  so  modifying  the 
morbid  action  existing  in  them  as  to  diminish  its  intensity  and  in  time  to 
check  its  progress.     It  is  upon  this  principle  that  chronic  inflammations 


286  CHRONIC    CERVICAL    ENDOMETRITIS. 

of  the  fauces,  urethra,  bladder,  and  many  other  mucous  surfaces  are 
treated,  and  it  is  equally  applicable  to  the  part  which  we  are  considering. 
Alterative  and  escharotic  substances  may  be  applied  to  the  lining  mem- 
brane of  the  cervix  uteri  in  the  following  ways :  by  painting  solutions 
over  the  canal  by  a  brush  or  dossil  of  lint,  by  touching  the  whole  diseased 
area  with  drugs  in  solid  form,  or  by  leaving  them  for  varying  lengths  of 
time  in  contact  with  the  walls  of  the  canal  in  a  solid  form,  or  upon  cotton 
which  has  been  saturated  with  solutions  of  them. 

Should  the  case  be  one  of  short  standing  and  of  no  great  degree  of 
severity,  the  cervical  canal  should  be  thoroughly  painted  over  with  the 
compound  tincture  of  iodine,  a  strong  solution  of  nitrate  of  silver,  glycerine 
saturated  with  tannin,  or  a  saturated  solution  of  carbolic  acid.  This  may 
be  done  by  using  a  brush  of  pig's  bristles,  which  is  far  superior  to  one  of 
camel's  hair ;  or,  by  wrapping  cotton  around  a  delicate  probe  of  silver  or 
whalebone  and  saturating  this  with  the  solution.  Emmet's  silver  or 
Budd's  vulcanite  probe  answers  an  excellent  purpose. 


Fig.  114. 


Budd's  elastic  probe. 


^^ 


Should  the  practitioner  prefer  to  use  a  solid  caustic,  the  nitrate  of  silver 
may,  with  great  advantage,  be  employed,  though  the  means  generally 
adopted  for  applying  this  substance  are  inefficient.  If  a  straight  stick  of 
lunar  caustic  be  fixed  in  a  quill  or  held  in  the  grasp  of  a  pair  of  forceps 
and  passed  into  the  os,  by  no  possibility  can  the  procedure  accomplish 
what  is  desired.  It  may  cauterize,  and  will  probably  do  so  with  objec- 
tionable thoroughness,  a  quarter  or  half  an  inch  of  the  lower  portion  of 
the  canal;  but  how  can  it  be  expected  to  go  upwards  for  an  inch  and  a 
quarter  and  come  in  contact  with  the  whole  surface  inflamed,  a  surface 
remarkable  for  its  inequalities  and  convolutions?  Sir  Benjamin  Brodie 
many  years  ago,  according  to  Dr.  Barnes,  of  London,  advised  fusing 
nitrate  of  silver  and  allowing  it  to  cool  upon  the  tip  of  a  probe  for  cauter- 
izing sinuous  tracts;  and  Chassaignac,  of  Paris,  applied  the  same  sub- 
stance to  the  cavity  of  the  womb  by  coating  platinum  wires  with  it.  Dr. 
F.  D.  Lente,  of  Cold  Spring,  N.  Y.,  has  experimented  extensively  in 
reference  to  this  subject,  and  the  result  of  his  investigations  has  been  to 
furnish  the  profession  with  the  best  and  most  reliable  of  all  the  means  at 
our  command  for  applying  solid  lunar  caustic  to  the  mucous  lining  of  the 
uterus.  Other  methods  which  have  been  suggested  and  employed  are 
these  :  the  use  of  Lallemand's  porte-eaustique  ;  leaving  a  pellet  of  nitrate 
of  silver  in  the  uterine  cavity  to  dissolve  ;  carrying  up  a  small  piece  held 
in  a  delicate  wire  casing,  etc. ;  but  none  of  these  compare  with  Dr.  Lente's, 


ALTERATIVE    APPLICATIONS.  287 

which  is  thus  practised.  A  probe,  somewhat  similar  to  the  ordinary  uterine 
probe,  is  warmed  and  then  dipped  in  a  little  platinum  cup  that  contains 
nitrate  of  silver  which  has  been  fused  over  a  spirit-lamp.  Removing  the 
probe  after  dipping  it,  and  waving  it  for  a  few  seconds,  a  film  of  the  nitrate 
will  be  found  to  have  covered  its  tip.  It  may  then  be  again  dipped,  and 
the  process  repeated  until  a  sufficiently  large  pellet  is  made  to  cover  the 
end  of  the  instrument.     Figs.  115  and  116  represent  the  probe  and  cup. 

Fig.  115. 


Lente's  silver  caustic  probe. 
Fig.  116. 


Lente's  cup  for  fusing  nitrate  of  silver. 

The  cervical  canal  having  been  cleansed  of  mucus,  and  its  direction 
learned  by  the  ordinary  probe,  Lente's  probe  is  passed  up  and  rubbed 
against  every  part  of  its  investing  membrane,  and  dipped  as  carefully  as 
possible  into  its  convolutions  before  removal. 

After  such  an  application,  a  stream  of  water  should  be  projected  against 
the  cervix,  and  a  pledget  of  cotton,  which  has  been  freely  saturated  with 
glycerine,  with  a  bit  of  thread  attached,  should  be  placed  against  it.  By 
means  of  the  thread  this  may  be  removed  by  the  patient  in  twelve  hours. 

The  walls  of  the  cervical  canal  may  also  be  thoroughly  cauterized  by 
the  introduction  and  retention  of  Braxton  Hicks's  crayons  of  sulphate  of 
copper,  iron,  zinc,  or  alum  cast  in  a  mould  of  the  length  and  size  of  the 
canal.  The  gelatine  crayons  of  Chamberlain  also  answer  very  well. 
They  are  introduced  into  the  cervical  canal  and  kept  in  situ  by  a  roll  of 
cotton.  The  zinc  points  may  be  allowed  to  dissolve,  as  they  give  no  pain  in 
doing  so.  Those  of  iron,  alum,  and  copper  should  have  a  thread  attached 
by  which  the  patient  may  remove  them  when  they  cause  discomfort. 

Alteratives  in  combination  with  cocoa-butter  may  be  made  into  sup- 
positories two  inches  in  length,  and  left  in  the  cervical  canal.  Into  these 
cervical  suppositories  may  be  introduced  zinc,  copper,  iron,  lead,  or  bis- 
muth, with  opium,  conium,  or  hyoscyamus. 

Fig.  117  represents  an  instrument,  originated  by  Dr.  Sims,  which  con- 
sists of  a  silver  probe  surmounted  by  a  slide,  by  means  of  which  a  roll  of 
cotton  soaked  in  any  medicated  solution  may  be  left  within  the  cervical 
canal. 

Two  inches  of  the  probe  are  wrapped  with  cotton  which  is  soaked  with 


288  CHRONIC    CERVICAL    ENDOMETRITIS. 

the  solution  selected,  and  then  passed  into  the  cervical  canal  so  as  to  be 
engaged  within  the  os  internum.    The  roll  of  medicated  cotton  is  then  slid 

Fio.  117. 


Silver  probe  with  cotton  wrapped  around  it  and  thread  attached. 


off  by  the  slide  and  retained  within  the  canal,  while  the  probe  is  with- 
drawn. In  twelve  hours  the  patient  makes  traction  upon  the  thread 
attached  to  the  cotton  and  it  is  removed. 

Destruction  and  Ablation  of  the  Diseased  Glands As  every  gynecol- 
ogist must  have  found  out  by  annoying  experience,  there  are  cases  of  this 
affection  which  prove  incurable  by  any  and  all  of  these  means.  They  are 
instances  not  of  granular  disease,  but  of  aggravated  inflammation  of  the 
mucous  follicles.  It  is  in  these  cases  that  a  long,  glairy,  and  extremely 
tenacious  plug  of  mucus  is  seen  hanging  from  the  os  externum,  which  it 
is  often  found  almost  impossible  to  remove  completely.  Month  after 
month  they  tax  the  ingenuity  and  perseverance  of  the  practitioner,  and  at 
the  end  of  his  efforts  they  seem  as  aggravated  in  character  as  they  were 
before.  Under  these  circumstances  but  one  resource  remains,  that  is  to 
fulfil  the  indication  which  is  so  often  elsewhere  adopted  in  surgery,  to 
destroy  or  remove  the  habitat  of  a  disease  which  is  not  susceptible  of  cure. 
This  has  been  done  by  some,  by  the  use  of  potassa  fusa  and  the  actual 
cautery,  but  against  both  I  would  strongly  advise,  for  they  produce  a  great 
deal  of  subsequent  cicatricial  contraction.  Dr.  John  Byrne  informs  me 
that  he  introduces  with  good  effect  an  electrode  of  the  galvanic  cautery, 
which  fits  the  canal,  to  the  os  internum,  and  then  by  establishing  a  cur- 
rent makes  it  white  hot.     I  know  nothing  of  the  plan  personally. 

One  of  the  best  chemical  agents  for  destroying  the  glands  is  fuming 
nitric  acid.  This  should  be  carefully  applied  to  the  canal  hy  means  of  a 
film  of  cotton  wrapped  around  the  silver  probe,  after  the  canal  has  been 
thoroughly  cleansed.  After  its  use,  a  stream  of  cold  water  should  be 
thrown  by  the  syringe  against  the  cervix,  and  a  wad  of  cotton  saturated 
with  glycerine  applied.  In  ten  days  or  a  fortnight  a  slough  of  the  cervi- 
cal mucous  membrane  will  take  place,  after  which  the  surface  should  be 
painted  over  twice  a  week  with  a  solution  of  nitrate  of  silver  9j  to  water  3j. 

Another  good  caustic  is  a  saturated  solution  of  chromic  acid,  which, 
though  not  nearly  as  powerful  as  the  nitric  acid,  answers  very  well. 

These  an;  the  only  agents  which  I  would  recommend  for  this  purpose. 
Nitrate  of  silver  is  not  sufficiently  powerful,  and  potassa  fusa  and  the  actual 
cautery  are  too  destructive  in  their  results. 


DESTRUCTION    AND    ABLATION    OF    DISEASED    GLANDS.      289 

In  alluding  to  these  cases  Dr.  West1  says :  "  I  am  disposed  to  think, 
however,  that  in  the  most  obstinate  cases  it  may  be  expedient  to  adopt  a 
suggestion  of  M.  Huguier,  of  which  I  have  but  small  experience,  though  I 
have  followed  it  with  benefit  on  two  or  three  occasions.  He  is  accustomed 
to  scarify  the  interior  of  the  cervical  canal  with  a  small,  curved,  narrow- 
bladed,  blunt-pointed  bistoury  before  introducing  the  caustic.  The  pre- 
vious scarification  exposes  the  more  deep  seated  follicles,  which  would 
otherwise  altogether  escape  the  action  of  the  remedy ;  and,  while  M. 
Huguier  states  that  he  has  never  known  any  mischief  follow  this  pro- 
ceeding, he  has  by  its  repetition  two  or  three  times  effected  the  cure  of 
cases  that  resisted  every  other  mode  of  treatment." 

In  these  very  obstinate  cases  I  have  repeatedly  resorted  to  a  surgical 
procedure  which  accomplishes  the  removal  of  these  glands,  and  which  I 
have  never  seen  followed  by  subsequent  contraction  or  inflammation. 

This  consists  in  the  application  of  the  cutting  steel  curette,  represented 
in  Fig.  118,  so  forcibly  as  to   remove   the  arbor  vita?  and  mucous  glands 

Fig.  118. 


Sims's  curette,  representing  the  angles  at  -which  it  may  be  bent. 

from  the  os  internum  to  the  os  externum.  Sometimes  a  second  operation 
in  two  or  three  weeks  after  the  first  has  been  necessary,  and  sometimes 
even  a  third.  By  this  means  I  have  succeeded  in  curing  some  most 
obstinate  cases  which  had  resisted  cure  by  all  other  means  except  the 
destructive  caustics  to  which  I  have  alluded.  The  use  of  this  method 
should  be  looked  upon  as  an  operation,  and  the  patient  guarded  just  as 
carefully  against  inflammation  as  she  would  be  after  section  of  the  neck 
or  any  kindred  procedure.  I  am  fully  aware  that  there  are  many  who  will 
at  once  characterize  this  procedure  as  harsh  and  unnecessary,  but  as  I  feel 
certain  that  it  is  neither,  and  as  I  have  had  experience  enough  with  it  to 
know  that  it  meets  the  requirements  of  a  class  of  cases  which  are  incurable 
by  other  means,  I  strongly  press  its  claims  to  a  fair  trial.  This  operation 
is  not  parallel  with  the  application  of  the  curette  to  the  body  of  the  uterus 
for  vegetations.  It  consists  in  what  is  equivalent  to  amputation  of  the 
glands,  and  is  the  counterpart  of  removal  of  the  follicular  surfaces  of  the 
tonsils  when  chronic  inflammation  of  the  follicles  proves  incurable.  Ex- 
tended experience  with  it  in  these  otherwise  intractable  cases  leads  me  to 
preserve  my  appreciation  of  its  value. 

1  West,  op.  cit. 
19 


290 


CHRONIC    CORPOREAL    ENDOMETRITIS. 


CHAPTER    XIX. 

CHRONIC  CORPOREAL  ENDOMETRITIS. 

Like  the  cervix,  the  body  of  the  uterus  is  liable  to  chronic  inflammation 
confined  to  its  lining  mucous  membrane.  This  receives  the  name  of 
chronic  corporeal  endometritis. 

Synonyms. — This  disease  has  been  described  under  the  names  of  endo- 
metritis, uterine  catarrh,  uterine  leucorrhcea,  and  internal  metritis.  The 
precise  seat  of  the  affection  is  pointed  out  by  the  dots  in  Fig.  119. 

Fig.  119. 


The  dots  show  the  site  of  corporeal  endometritis. 

Frequency Few  points  in  uterine  pathology  have  created  more  discus- 
sion of  late  years  than  this.  Some  excellent  authorities,  following  the  lead 
of  Dr.  Henry  Bennet,  regard  it  as  of  rare  occurrence,  while  a  large  ma- 
jority consider  it  quite  common.  "  Internal  metritis,"1  says  Aran,  "  is 
more  frequent,  nevertheless,  in  spite  of  all  that  has  been  said  to  the  con- 
trary, in  the  cavity  of  the  body  than  in  the  cavity  of  the  neck  of  the 
womb ;"  and  this  opinion  is  concurred  in  by  Dr.  West  and  others.  To 
show  how  unsettled  this  point  is  in  the  present  state  of  pathology,  let  me 


•  Mai.  de  l'UtSrus,  p.  408. 


ANATOMY.  291 

contrast  with  this  statement  that  of  Prof.  Byford,1  of  Chicago,  in  his  ex- 
cellent work  on  Medical  and  Surgical  Treatment  of  Women  :  "  Inflamma- 
tion limited  to  the  cavity  of  the  body  of  the  uterus  is  not  common,  but  I 
am  quite  sure  that  I  have  met  with  at  least  two  instances."  "While  Dr. 
Byford's  experience  furnishes  him  but  two  instances,  Dr.  Tilt  gives  the 
statistics  of  fifty  cases  of  which  he  has  kept  notes,  and  Klob  declares  the 
disease  to  be  quite  common. 

The  more  industriously  the  student  of  gynecology  interrogates  the  litera- 
ture of  this  subject,  the  more  unsettled  are  his  conclusions  likely  to  be, 
and  unfortunately  his  own  investigations,  however  carefully  conducted, 
will  often  fail  to  enlighten  him  in  the  individual  cases  with  which  he  meets, 
for  the  differential  diagnosis  between  cervical  and  corporeal  endometritis 
is  often  very  difficult.  My  own  opinions  upon  this  important  point  I  shall 
state  freely,  unbiassed  by  those  of  authors  for  whom  I  entertain  the  high- 
est respect,  but  whose  conclusions  conflict  with  what  I  have  carefully  ob- 
served at  the  bedside. 

The  most  frequent  locality  of  uterine  inflammation  is  that  portion  of  the 
uterus  below  a  line  running  across  it  through  the  os  internum.  The  por- 
tion of  the  organ  above  this  line,  however,  is  much  more  commonly  affected 
by  inflammatory  disease  than  is  stated  by  Dr.  Bennet.  During  eighteen 
months  I  met,  in  private  practice  alone,  nine  well-marked  and  unquestion- 
able cases,  and  with  several  more  in  which  I  could  not  satisfy  myself  as  to 
the  exact  limit  of  the  disease.  The  lining  membrane  of  body  and  cervix 
may  be  simultaneously  affected,  but  this  is  the  exception  and  not  the  rule  ; 
generally  we  find  one  or  other  portion  of  the  organ  the  seat  of  disease.  In 
making  this  last  assertion  I  am  fully  aware  of  its  importance,  and  of  the 
fact  that  it  will  be  dissented  from  by  a  great  many.  But  feeling  convinced, 
as  I  do,  that  upon  its  non-recognition  depends  a  certain  amount  of  the  ob- 
scurity attending  the  differentiation  of  disease  of  the  neck  and  body,  I 
wish  to  fix  the  attention  of  the  reader  upon  it. 

Anatomy — If  the  mucous  membrane  of  the  uterus  be  examined  with  a 
lens,  it  will  be  seen  to  be  studded  with  minute  openings  somewhat  similar 
to  the  mouths  of  the  glands  of  Lieberkiihn  in  the  intestines.  These  are 
the  mouths  of  long,  curling  follicles,  which  project  by  their  closed  extremi- 
ties downwards  towards  the  parenchyma  of  the  organ.  They  are  lined  by 
delicate  epithelium,  their  lining  membrane  consisting  merely  of  involutions 
of  that  of  the  uterus.  These  glands  are  of  two  kinds  :  the  simple,  which 
are  unbranched  tubes  ;  and  the  compound,  which  have  several  branches. 
Besides  these  glands  there  are  intermixed  with  them  mucous  crypts, 
which  sometimes  become  distended  so  as  to  form  the  so-called  "  channel 
polypus." 

Between  these  glands  ramify  numerous  capillaries,  which  dip  down  and 

1  Op.  cit.,  p.  182. 


292  CHRONIC    CORPOREAL    ENDOMETRITIS. 

form  a  network  about  their  mouths  so  superficial  that  they  are  sometimes 
seen  by  a  strong  glass  completely  uncovered,  and  even  projecting  like  villi 
into  the  cavity. 

Pathology Corporeal  endometritis  is,  like  the  same  affection  in  the 

cervix,  a  glandular  disease.  The  utricular  follicles  are  the  seat  of  dis- 
order, and  it  is  to  the  exaggeration  of  their  secretory  function  that  is  due 
the  uterine  leucorrhoea  which  constitutes  one  of  its  prominent  symptoms. 

The  post-mortem  appearances  of  the  mucous  membrane  are  these :  it  is 
found  to  be  swollen,  soft,  pale,  and  smooth,  or  covered  over  with  granula- 
tions. In  cases  which  have  lasted  very  long,  the  utricular  glands  are  in 
great  numbers  obliterated,  or,  atrophy  having  taken  place  at  their  mouths 
only,  their  secretions  are  retained,  and  they  are  distended  into  cysts.  In 
time  the  mucous  membrane  is  replaced  by  a  thin  layer  of  connective  tissue, 
which  is  covered  not  by  cylindrical  or  ciliated  epithelium,  but  by  what 
resembles  that  of  basement  character.  At  times  small  mucous  polypi  are 
found  in  the  cavity,  while  at  others,  a  closure  of  the  os  internum  uteri 
having  been  effected  by  adhesion,  hydrometra  exists. 

I  have  had  three  opportunities  for  examining  post  mortem  into  the 
pathology  of  this  disease.  Two  of  these  cases  were  presented  to  the  Ob- 
stetrical Society  of  this  city.  In  these  instances  the  condition  described 
by  Scanzoui  was  most  evident.  The  uterine  cavity  was  found  considerably 
enlarged,  its  walls  diminished  in  thickness,  and  in  one  instance  they  were 
pronounced  by  Dr.  J.  B.  Reynolds,  after  microscopical  examination,  to  be 
in  a  state  of  fatty  degeneration.  The  uterine  neck  was  in  every  case  found 
healthy  both  as  to  parenchymatous  and  mucous  structure,  and  the  enlarged 
body  displaced  by  anterior  or  posterior  flexure.  The  mucous  lining  of 
the  body  was  in  two  cases  quite  smooth,  and  to  a  great  extent  deprived 
of  epithelium ;  while  in  the  third  it  was  roughened,  and  presented  points 
where  the  enlarged  bloodvessels  created  a  number  of  reddish  spots.  But 
enlargement  of  the  uterine  cavity  is  not  always  present;  it  marks  chronic 
cases,  and  will  not  be  recognized  in  those  of  recent  origin.  It  is  highly 
probable,  too,  that  in  cases  of  recent  origin  the  pathological  appearances 
which  have  been  here  described  would  not  be  found  to  exist,  but  in  place 
of  them  a  thickened,  congested,  and  florid  appearance  would  present  itself. 

Prognosis. — The  prognosis  of  chronic  inflammation  of  the  uterine  body 
is  always  grave  with  reference  to  cure.  Even  if  the  case  be  not  of  very 
serious  character,  and  have  lasted  only  a  short  time,  the  possibility  of 
rapid  recovery  is  doubtful,  while,  if  it  have  continued  for  a  number  of 
years,  it  will  often  prove  incurable.  Scanzoni1  says,  with  a  candor  which 
does  him  honor:  "As  for  ourselves  we  do  not  remember  a  single  case 
where  we  have  been  able  to  cure  an  abundant  uterine  leucorrhoea  of  several 
years'  standing."    In  most  cases  a  certain  amount  of  amelioration  may  be 

1  Scanzoni,  Diseases  of  Females,  Am.  ed.,  p.  202. 


CAUSES. 


293 


effected  even  when  they  are  of  long  standing  ;  in  a  certain  number  treated 
early,  cure  may  unquestionably  be  accomplished ;  while  in  a  great  many, 
nothing  whatever,  either  in  the  way  of  cure  or  of  relief,  can  be  obtained, 
and  the  patient,  after  passing  from  physician  to  physician,  settles  down 
into  a  careful  mode  of  life,  resolved  to  cease  treatment  and  bear  as  best 
she  may  an  evil  which  she  has  learned  to  regard  as  incurable. 

The  symptoms  of  a  favorable  and  unfavorable  case  of  corporeal  endo- 
metritis may  be  thus  contrasted  : — 


Prognosis  is  Favorable  when 
The  case  is  of  recent  standing  ; 
The  discharge  is  of  mucus  or  blood  ; 
Dysmenorrhocal  shreds  are  not  cast  off ; 
Patient  naturally  of  strong  constitution  ; 
Connective  tissue  is  not  affected  ; 
Dimensions  of  cavity  are  not  increased  ; 

Nervous  system  is  not  involved ; 
Patient  near  menopause. 


Prognosis  is  Unfavorable  when 
The  case  is  of  long  standing  ; 
The  discharge  is  purulent ; 
Dysmenorrhceal  shreds  are  cast  off; 
Patient  naturally  of  feeble  constitution  ; 
Connective  tissue  is  affected  ; 
Dimensions  of  cavity  are  decidedly  in- 
creased ; 
Nervous  system  is  involved  ; 
Patient  not  near  menopause. 


Predisposing  Causes It  has  been  noticed  most  frequently  to  have  de- 
veloped itself  in  women  showing  a  tendency  to  the  following  conditions : — 
Scrofula  ; 
Tuberculosis ; 
Spanamiia  ; 

Exhaustion  from  parturition  ; 
Exhaustion  from  lactation  ; 
Great  and  prolonged  nervous  depression. 

Exciting  Causes — These  may  be  enumerated  as  follows  : — 
Exposure  during  menstruation  ; 
Sudden  checking  of  the  menstrual  flow  ; 
Obstruction  to  escape  of  menstrual  blood  ; 
Abortion  and  parturition  ; 
Cervical  endometritis  ; 
Acute  endometritis,  puerperal  or  not ; 
Subinvolution  ; 

Displacements  causing  great  congestion  ; 
Chronic  pelvic  peritonitis ; 
Abuse  of  sexual  intercourse  : 
Injury  from  sounds  or  intra-uterine  pessaries,  and  injuries  resulting 

from  attempts  to  produce  abortion  ; 
Certain  hemic   conditions,  as  those   accompanying  phthisis  and   the 

exanthematous  diseases  ; 
Tumors  in  the  uterine  cavity  or  walls ; 
Vaginitis,  specific  or  simple. 


294  CHRONIC    CORPOREAL    ENDOMETRITIS. 

It  is  quite  clear  how  either  of  the  first  two  causes,  in  checking  hemor- 
rhage from  the  congested  mucous  lining  of  the  uterine  body,  may  at  once 
induce  the  first  stage  of  the  disease.  They  generally  result  in  the  acute 
variety,  which  passes  off  rapidly,  but  which  sometimes  ends  in  the  chronic 
form. 

Obstruction  to  escape  of  menstrual  blood  is  a  very  fruitful  source  of  the 
affection.  The  menstrual  blood,  if  it  pour  at  once  into  the  vagina,  remains 
fluid  from  admixture  of  an  acid  mucus  secreted  by  the  lining  membrane 
of  that  canal ;  but  if  it  be  imprisoned  in  the  uterine  cavity,  where  only 
an  alkaline  mucus  exists,  it  very  soon  becomes  clotted.  These  clots  are 
too  large  to  pass  through  a  cervix  of  normal  dimensions,  and,  of  course, 
cannot  escape  from  one  unnaturally  constricted.  Their  presence  in  the 
uterine  cavity,  together  with  that  of  blood  which  they  imprison,  in  time 
excites  contraction,  by  which  they  are  expelled.  This  repeated  dilatation 
and  contraction  cannot  last  long  without  exciting  inflammation  in  the 
mucous  membrane  of  the  uterus.  Such  an  obstruction  may  have  as  its 
cause  a  small  polypus  which  acts  as  a  ball  valve  at  the  os  internum,  con- 
genital or  acquired  narrowness  of  the  cervical  canal,  or  uterine  flexion. 

The  parturient  process  is  a  very  frequent  source  of  the  disease,  espe- 
cially where  the  undeveloped  placenta  is  prematurely  separated  from  its 
uterine  connection.  Where,  in  a  prolonged  labor,  the  early  evacuation 
of  the  liquor  amnii  leaves  the  irregular  outline  of  the  body  of  the  child 
pressing  against  the  uterine  investment  for  many  hours,  such  a  sequel 
might  result. 

Of  cervical  inflammation  as  an  exciting  cause  Dr.  Bennet1  thus  ex- 
presses himself:  "  It"  (corporeal  endometritis)  "appears,  however,  to  be 
generally  met  with  in  practice  as  the  result  of  the  lengthened  existence 
of  inflammatory  disease  of  the  cervix  and  its  cavities.  The  inflammation 
gradually  progresses  along  the  cavity  of  the  cervix  until  it  reaches  the  os 
internum,  and  passes  into  the  uterus."  I  have  already  stated  my  dissent 
from  this  view,  although,  at  the  same  time,  I  admit  that  it  may  be 
correct. 

Acute  endometritis  may,  instead  of  subsiding  entirely,  very  naturally 
run  into  this  disease. 

Subinvolution  of  the  uterus  keeps  up  a  constant  tendency  to  hyperemia 
of  the  parenchyma  which  affects  the  mucous  membrane.  As  a  complica- 
tion of  this  condition  corporeal  endometritis  is  more  commonly  observed 
than  as  a  consequence  of  all  the  other  causes  combined. 

Pelvic  peritonitis  disturbs  the  position,  the  innervation,  and  the  circu- 
lation of  the  uterus,  and  proves  a  fruitful  source  of  endometritis. 

The  effect  of  sexual  intercourse  as  a  causative  influence  is  frequently 
observed    soon    after    marriage,  the    first  connubial  approaches  exciting 

1  Op.  cit.,  p.  75. 


SYMPTOMS.  295 

uterine  congestion  with  greater  or  less  intensity.  Dr.  Tilt1  remarks  with 
reference  to  it:  "  It  is  useless  to  disguise  the  fact,  connection  has  a  down- 
right poisonous  influence  on  the  generative  organs  of  some  women."  I 
cannot  believe  that  the  Almighty  has  ordained  a  function  as  essential  to 
the  perpetuation  of  our  species  which  has  a  downright  poisonous  influ- 
ence on  the  generative  organs  of  a  healthy  woman.  And  yet,  to  a  certain 
extent,  the  statement  is  correct,  for  upon  a  woman  who  has  enfeebled  her 
system  hy  habits  of  indolence  and  luxury,  pressed  her  uterus  entirely  out 
of  its  normal  place,  and  perhaps  goes  to  the  nuptial  bed  with  some  lurking 
uterine  disorder,  the  result  of  imprudence  at  menstrual  epochs,  sexual 
intercourse  has  indeed  such  an  influence.  The  taking  of  food  into  the 
stomach  exerts  no  injurious  influence  on  the  digestive  system,  but  the 
taking  of  food  by  a  dyspeptic  who  has  abused  and  injured  the  organ  may 
do  so. 

Injuries  from  sounds,  etc.,  act  so  evidently  in  exciting  inflammation  as 
to  need  only  mention. 

Certain  conditions  of  the  blood  sometimes  produce  acute  corporeal  en- 
dometritis, which,  as  already  stated,  may  pass  into  the  form  under  con- 
sideration. As  a  complication  of  the  exanthematous  diseases,  endometri- 
tis is  well  known,  and  its  occurrence  with  phthisis  has  been  noted  by  Dr. 
Gardner  in  the  American  edition  of  Scanzoni.  Every  practitioner  must 
have  noticed  it  in  connection  with  that  affection. 

Tumors  in  the  cavity  or  walls  of  the  uterus  very  generally  produce  this 
disease  in  consequence  of  the  congestion  of  the  mucous  membrane  which 
they  cause. 

Vaginitis  of  non-  specific  character  may,  and  of  specific  form  often  does, 
pass  by  continuity  of  structure  into  the  neck  and  body  of  the  uterus. 
The  latter  has  in  these  cases  in  my  experience  not  only  affected  the  body, 
but  the  Fallopian  tubes,  resulting  in  peritonitis. 

Symptoms — The  symptomatology  of  corporeal  endometritis  constitutes 
one  of  the  most  unsatisfactory  and  obscure  subjects  in  the  entire  field  of 
gynecology.  At  times  its  symptoms  are  so  slight  and  at  others  so  masked 
and  obscure,  that  the  disease  often  runs  a  lengthy  course  without  exciting 
the  suspicions  of  either  physician  or  patient.  Its  effects  upon  the  consti- 
tution also  differ  most  unaccountably  in  different  cases.  Sometimes  the 
disease  will  continue  for  ten,  fifteen,  or  twenty  years,  producing  profuse 
leucorrhoea,  menstrual  disorders,  and  nervous  derangement,  and  yet  result 
in  no  annoyance  so  grave  as  to  cause  the  patient  to  seek  medical  aid. 
At  others  it  accompanies  or  excites  areolar  hyperplasia,  which  induces 
displacement  and  causes  pain  on  locomotion,  sexual  intercourse,  and  the 
passage  of  feces  through  the  rectum  ;  or  results  in  an  ichorous  discharge, 
which  creates   the   annoying   symptoms  of  vaginitis,  cystitis,  or  pruritus 

«  Op.  cit.,  p.  234. 


296  CHRONIC    CORPOREAL    ENDOMETRITIS. 

vulvae.     The  chief  symptoms  which  usually  present  themselves  in  a  case 
of  mucous  inflammation  of  the  uterine  body  are — 

Leucorrhoea  ; 

Menstrual  disorders ; 

Pain  in  the  back,  groins,  and  hypogastrium ; 

Nervous  disorders ; 

Tympanites  ; 

Symptoms  of  pregnancy ; 

Sterility. 
Profuse  leucorrhoea  of  glairy  character  is  one  of  the  chief  signs  of  the 
affection.  This  when  very  tenacious  and  thick  is  the  product  of  the  cer- 
vical glands,  but  the  lining  membrane  of  the  uterus  likewise  secretes  a 
similar  fluid,  differing  from  it  chiefly  in  possessing  the  qualities  mentioned 
in  a  very  much  less  marked  degree.  But  uterine  leucorrhoea  differs  from 
cervical  in  other  particulars ;  it  is  often  more  or  less  mixed  with  blood  so 
as  to  have  a  rust-colored  appearance,  especially  for  a  fortnight  after  men- 
struation. This,  Dr.  Bennet1  looks  upon  as  being  "  as  characteristic  of 
internal  metritis  as  the  rust-colored  expectoration  is  of  pneumonia."  It 
is  a  reliable  and  valuable,  though  by  no  means  a  universal,  sign.  Some- 
times the  menstrual  discharge  is  regarded  by  the  patient  as  greatly  pro- 
longed, when  in  reality  it  is  this  blood-stained  leucorrhoea  which  follows 
the  process  of  menstruation,  that  gives  rise  to  the  belief.  In  some  in- 
stances the  discharge  is  milky,  and  at  others,  and  these  are  the  most 
rebellious  cases,  perfectly  purulent.  There  is  a  variety  of  corporeal  endo- 
metritis which  occurs  in  old  women  who  have  long  ceased  to  menstruate, 
in  which  a  watery  or  creamy  pus  is  secreted.  These  cases  are  often 
accompanied  by  the  most  wearing  and  harassing  pruritus  vulvae. 

Menstrual  disorders  are  rarely  absent.  The  discharge  is  sometimes  too 
profuse,  even  lasting  throughout  the  month  and  constituting  menorrhagia, 
or  it  is  very  scanty,  and  shows  a  marked  tendency  to  cessation. 

Where  the  connective  tissue  is  entirely  unaffected,  menorrhagia  may 
occur  without  pain,  but  this  is  not  common,  for  that  tissue  is  often  simul- 
taneously involved  and  dysmenorrhoea  coexists.  Sometimes  in  these 
cases,  an  exfoliation  of  the  entire  lining  membrane  of  the  cavity  of  the 
uterine  body  occurs  at  the  menstrual  periods.  This  has  received  the 
name  of  the  dysmenorrhoeal  membrane,  and  is  by  some  regarded  as  an 
evidence  of  chronic  corporeal  endometritis. 

Pain  in  the  back,  groins,  and  hypogastrium  is  generally  present,  and 
at  times  a  burning  sensation  over  the  symphysis  pubis  proves  a  source  of 
great  discomfort. 

Nervous  symptoms  of  greater  or  less  severity  generally  show  themselves 
before  the  disease  has  lasted  long.     The  patient  complains  of  neuralgic 

1  Op.  cit.,  p.  76. 


COURSE.    DURATION,    AND    TERMINATION.  297 

headache,  especially  over  the  crown,  hysterical  symptoms,  with  sadness, 
tendency  to  weep,  and  a  feeling  of  intense  isolation  and  incapacity  for  any 
mental  effort. 

Meteorism  is  a  very  common  symptom,  the  connection  of  which  with 
inflammation  of  the  uterine  mucous  memhrane  is  not,  at  first  glance,  clear. 
It  is  probably  due  to  disorder  of  the  nervous  influences  governing  peris- 
talsis and  giving  tone  to  the  intestinal  muscular  tissue,  which  proceeds  to 
such  an  extent  as  to  result  in  accumulation  of  gases  in  the  canal.  In  the 
same  way  this  affection  may  induce  constipation,  which  is  often  one  of  its 
most  obstinate  accompaniments. 

Symptoms  of  pregnancy  often  exist  in  connection  with  the  disease,  and 
sometimes  mislead  the  physician.  Nausea  and  vomiting  are  by  no  means 
invariably  present,  but  are  valuable  signs.  They  appear  to  result  from 
this  disease  as  they  do  from  occupation  of  the  uterine  cavity  by  the  pro- 
duct of  conception.  Sometimes,  in  addition  to  these,  there  are  darkening 
of  the  areola?  of  the  breasts,  and  enlargement  and  sensitiveness  of  the 
mammary  glands.  When  to  these  are  added  abdominal  enlargement, 
from  tympanites  and  irregularity  of  menstruation,  it  will  be  perceived  how 
easily  an  error  might  be  made. 

Sterility  is  so  commonly  a  result  of  endometritis  that  it  should  be  con- 
sidered as  one  of  its  signs.  Very  often  it  has  been  the  only  symptom  that 
has  led  to  an  investigation  of  the  state  of  the  uterus  which  has  determined 
the  existence  of  the  disease.  The  affection  does  not,  however,  preclude 
the  possibility  of  conception  ;  it  only  diminishes  the  probability. 

Physical  Signs — The  physical  signs  are  neither  numerous  nor  reliable. 
Those  of  real  value  only  will  be  mentioned.  The  uterine  probe  passed 
into  the  cavity  will  often  show  the  length  of  the  uterus  to  be  greater  than 
it  would  be  in  health,  and  create  more  discomfort  than  in  a  healthy  uterus. 
Upon  conjoined  manipulation,  two  fingers  being  placed  in  the  fornix 
vagina?,  and  the  fingers  of  the  other  hand  made  to  depress  the  anterior 
wall  of  the  abdomen,  sensitiveness  will  usually  be  found  in  the  body  of 
the  organ.  The  recognition  of  the  absence  of  cervical  disease,  while  at 
the  same  time  there  are  profuse  uterine  leucorrhcea  and  the  other  symp- 
toms recorded,  will  lead  us  strongly  to  suspect  corporeal  endometritis. 
Lastly,  dilatation  of  the  os  internum  may  be  taken  as  a  corroborative 
sign. 

Course,  Duration,  and  Termination This  disorder  often  lasts  for  years ; 

in  the  case  of  a  nulliparous  woman  confining  itself  to  the  mucous  mem- 
brane ;  in  that  of  a  woman  who  has  borne  children  gradually  exciting 
congestion  and  exuberant  growth  in  the  subjacent  parenchyma.  This  is 
the  most  frequent  result  exerted  upon  the  parenchyma,  but  it  may  be 
affected  in  two  ways:  1st,  a  hyperplasia,  or  excess  of  nutrition,  may 
occur;  2d,  an  aplasia,  or  want  of  nutrition,  may  take  place,  and  dilatation 
and  distention  eventuate. 


298  CHRONIC    CORPOREAL    ENDOMETRITIS. 

Complications. — The  most  ordinary  complications  met  with  are  dis- 
placement, vaginitis,  granular  degeneration  of  the  cervix,  and  pruritus 
vulvas. 

Treatment. — Special  attention  should  be  given  to  sustaining  and  im- 
proving the  general  health  of  the  patient,  which  will  often  show  a  marked 
tendency  to  depreciation.  Good  diet,  fresh  air,  systematic  exercise,  and 
avoidance  of  all  circumstances  calculated  to  depress  the  spirits  or  harass 
the  mind,  should  be  recommended.  If  practicable,  change  of  air  and 
scene  should  be  brought  to  our  aid,  and  the  patient  be  sent  occasionally  to 
some  suitable  watering-place  or  country  resort.  The  healthy  condition  of 
the  nervous  and  sanguineous  systems  will  be  fostered  by  these  measures, 
and  should  medicinal  tonics  be  required,  iron,  the  mineral  acids,  quinine, 
the  bromide  of  potassium,  or  nux  vomica  may  be  administered.  All  rich 
and  highly  spiced  food  should  be  avoided,  and  the  patient  should  be 
guarded  against  habits  of  indolence  and  luxury  which  tend  to  exhaust  the 
nervous  strength. 

The  uterus  should  be  placed  at  rest  by  removal  of  pressure  upon  the 
fundus  by  clothing,  limitation  of  marital  intercourse,  avoidance  of  violent 
and  intemperate  exercise,  and  if  necessary,  by  a  sustaining  pessary. 
Should  absolute  displacement  exist,  it  should  be  carefully  rectified;  should 
laceration  of  the  cervix  exist,  it  should  be  repaired ;  and  in  case  uterine 
enlargement  or  subinvolution  be  present,  ergot  in  small  doses  should  be 
systematically  administered. 

Applications  to  the  Uterine  Cavity Upon  theoretical  grounds  direct 

applications  to  the  diseased  endometrium  would  hold  out  a  brighter  prom- 
ise of  cure  in  these  cases  than  any  other  plan  of  treatment,  and  during  the 
past  quarter  of  a  century  it  has  become  the  conventional  habit  to  recom- 
mend them.  In  this  habit  I  have  shared  until  closer  observation  and 
enlarging  experience  during  the  past  five  years  have  led  me  to  become 
sceptical  as  to  the  utility  of  the  course.  Observation  and  experience 
have  so  changed  my  own  practice  that  I  find  myself  very  rarely  resorting 
at  present  to  applications  above  the  os  internum  uteri.  That  they  may 
become  necessary  in  certain  cases  I  do  not  at  all  deny;  but  I  maintain 
that  they  should  not  be  habitually  resorted  to  :  1st,  because  they  very 
generally  fail  in  curing  the  disease;  and,  2d,  because  they  are  by  no  means 
void  of  danger. 

That  a  certain  number  of  cases  of  pelvic  peritonitis  and  cellulitis  are 
created  by  these  applications  all  must  admit.  In  spite  of  this  fact  their 
use  would  be  decidedly  indicated  were  their  results  very  promising.  But 
in  my  experience  their  results  are  not  promising,  and  for  this  reason  I 
have  given  up  their  general  use.  I  shall  nevertheless  describe  the  methods 
by  which  such  applications  should  be  made  as  fully  as  possible. 

Recamier  was  the  first  who  had  the  boldness  to  cauterize  the  cavity  of 
the   uterus,  which  he  did   by  means  of  nitrate   of  silver  in  an  ordinary 


TREATMENT. 


299 


120. 


porte-caustique.  The  practice  thus  introduced  was  continued  and  spread 
abroad  by  Robert,  Richet,  Trousseau,  Maisonneuve,  and  others,  and  to-day 
is  still  commonly  resorted  to.  There  are  four  methods  by  which  it  may 
be  practised:  1st,  by  the  use  of  solutions  painted 
over  the  surface;  2d,  by  ointments  left  to  melt  in 
utero;  3d,  by  injections  of  fluid  into  the  cavity  of 
the  body;  4th,  by  solid  caustics.  In  commencing 
treatment  the  practitioner  should  see  that  the  cervi- 
cal canal  is  well  opened,  in  order  to  admit  the  free 
escape  of  fluids  from  the  cavity  above,  and  the  ap- 
plication of  substances  through  it  from  below.  This 
perviousness,  if  it  do  not  exist,  should  be  secured 
by  the  use  of  dilators  before  the  local  treatment  is 
proceeded  with.  If  the  uterus  be  found  sensitive  to 
vaginal  and  rectal  touch,  the  patient  should  remain 
in  bed  for  some  days  before  the  first  application  is 
made,  the  bowels  be  kept  active  by  mild  saline 
purgatives,  and  warm  baths  or  hip-baths  with  co- 
pious vaginal  injections  employed.  If  the  operator 
use  the  ordinary  long,  cylindrical  speculum,  he  will 
in  the  majority  of  cases  fail  to  accomplish  the  end 
in  view,  reaching  the  fundus  uteri,  for  through  such 
an  instrument,  it  is  always  difficult  to  penetrate  so 
high  into  the  cavity.  If,  however,  he  uses  the 
Sims  speculum,  or  one  of  its  modifications,  or  a 
short,  cylindrical  instrument,  he  will  succeed  with- 
out effort  or  delay.  The  instrument  being  intro- 
duced and  the  cervix  cleansed  by  the  speculum 
syringe,  the  operator  very  gently  passes  through 
the  cervical  canal  a  small  and  delicate  cervical 
speculum.  That  shown  in  Fig.  120  is  one  of  the 
best  of  its  kind. 

Having  previously  wrapped  the  silver  or  hard 
rubber  probe  with  a  film  of  cotton,  he  now  passes 
this  up  to  the  fundus.  This  removes  a  good  deal 
of  mucus  from  the  cavity  which  would  otherwise 
have  neutralized  the  caustic  introduced.  Removing 
the  cotton  from  the  probe,  he  wraps  another  piece 
around  it,  or,  as  is  better,  uses  another  probe  al- 
ready wrapped,  and,  dipping  this  into  the  fluid 
caustic  which  he  has  determined  to  use,  he  passes  it 

directly  to  the  fundus  and  gently  moves  it  over  the  surface.  This  should 
not  be  repeated,  for  the  astringent  action  of  the  caustic  makes  repetition 
difficult,  and  if  properly  done  the  first  time  it  will  be  unnecessary.      After 


Wylies's  cervical  specu- 
lum, with  probe  passing 
through  it. 


300  CHRONIC    CORPOREAL    ENDOMETRITIS. 

this  the  patient  should  go  to  bed  and  remain  perfectly  quiet,  until  the  next 
day  at  least,  and  if  any  discomfort  exist,  for  several  days. 

In  place  of  the  cotton-wrapped  probe,  the  painting  of  the  uterine  surface 
may  be  very  thoroughly  accomplished  by  the  use  of  a  small  brush  of  pig's- 
bristles  dipped  in  the  solution,  and  passed  through  the  cervical  speculum. 

The  alteratives  which  may  be  thus  employed  are : — 

Solution  of  chromic  acid  £j  to  §j  water ; 

Solution  of  nitrate  of  silver  9j  or  3ss  to  ^j  of  water ; 

Compound  tincture  of  iodine  §ss  to  §ss  of  glycerine. 

Saturated  solution  of  sulphate  of  zinc  ; 

Saturated  solution  of  sulphate  of  copper  ; 

U.  S.  D.  solution  persulphate  or  perchloride  of  iron  with  equal  parts  of  glycerine. 

Solution  of  chloride  of  zinc  5j  to  ^j  water  ; 

U.  S.  D.  muriate  tincture  of  iron  ajij  to  §j  water ; 

Saturated  solution  of  carbolic  acid. 

Use  of  Ointments — The  application  of  ointments  to  the  lining  mem- 
brane of  the  uterus  is  so  inconvenient  and  disagreeable  a  process  that  I 
cannot  recommend  it.  It  possesses  no  special  advantages.  It  is  proceeded 
with  in  much  the  same  manner  as  that  of  fluids,  except  that  a  different 
instrument  is,  of  course,  necessary  for  their  introduction.  One  which 
answers  the  purpose  very  well  is  the  invention  of  Dr.  F.  D.  Lente.  It 
consists  of  a  syringe  with  a  silver  tube  attached.  The  ointment  to  be 
employed  is  put  into  the  syringe  by  a  spatula,  and,  the  tube  being  intro- 
duced into  the  uterine  cavity,  the  piston  is  pushed  forward  and  the  oint- 
ment is  forced  out.  The  following  are  the  ointments  which  are  generally 
thus  employed,  though  any  others — as  lead,  bismuth,  calomel,  iodine,  etc. 
— might  be  substituted  : — 

B»  Argenti  nitratis,  !jij  ; 

Belladonna  ext.  3J  ; 

Ungt.  spermaceti,  Qij. — M. 

B-  Plumbi  acet.  3ij- 

Morph.  sulphat.  gr.  iv  ; 
Butyr.  cacao,  §ss  ; 
01.  olivae,  q.  s. — M. 

The  Application  of  Alteratives  of  Solid  CJiaracter  to  the  Endometrium. 
— Substances  of  solid  character  which  will  melt  under  the  influence  of  the 
heat  of  the  body  may  be  introduced  into  the  uterine  cavity  in  the  form  of 
suppositories  or  pencils.  The  pencils  of  zinc,  copper,  alum,  or  iron  men- 
tioned in  the  last  chapter  may  be  thus  employed,  or  suppositories  made 
with  cocoa-butter,  or  according  to  Becquerel's  formula,  may  be  used  in- 
stead.    Becquerel's  formula  is  the  following  : — 

B-  Tannin,  4  parts  ; 

Gum  tragacanth,  1  part; 
Bread  crumb,  q.  s. 
One  to  be  gently  pushed  into  the  uterine  cavity  and  allowed  to  melt,  every  four 
days. 


INJECTIONS    INTO    THE    UTERINE    CAVITY.  301 

Upon  first  trying  an  intra-uterine  suppository  or  pencil  of  a  certain 
strength,  I  should  advise  that  a  thread  be  always  attached  to  it  in  order 
that  it  may  be  removed  by  the  patient  in  case  of  pain.  After  testing  in 
this  way,  the  thread  may  be  dispensed  with,  but,  as  a  preliminary  precau- 
tion, its  necessity  is  great.  Cases  are  met  with  in  which  a  few  drops  of 
water  in  the  cavity  of  the  uterus  will  cause  pain,  and  I  have  seen  the  cau- 
tious introduction  of  the  uterine  sound  cause  violent  epileptiform  convul- 
sions. Should  such  a  result  follow  the  introduction  of  a  medicated  pencil 
which  has  slipped  out  of  reach,  the  position  of  the  introducer  would  be  an 
unfortunate  one. 

Injections  into  the  Uterine  Cavity — The  subject  of  intra-uterine  injec- 
tion has  often  come  very  prominently  before  the  profession,  and  been  fully 
and  ably  discussed.  Many  eminent  authorities  have  pronounced  in  its 
favor,  and  reported  hundreds  of  cases  in  which  they  have  employed  it  with 
impunity  and  benefit.  In  the  practices  of  many  it  is,  indeed,  a  routine 
method  of  treating  corporeal  endometritis.  While  the  evidence  which  has 
been  adduced  proves  that  with  proper  precautions  this  means  of  medica- 
tion is  robbed  of  its  chief  dangers,  it  likewise  makes  it  evident  that  in 
careless,  inexperienced,  or  unskilful  hands  it  carries  with  it  manifold  and 
serious  perils. 

This  method  of  treatment  is  not  a  new  one,  as  many  have  appeared  to 
think,  but  one  of  the  oldest  on  record.  It  is  certainly  a  suspicious  cir- 
cumstance that,  employed,  as  it  has  been  at  various  periods,  during  2000 
years,  it  should  have,  even  at  our  day,  as  many  opponents  as  it  now 
numbers  arrayed  against  it.  It  may  be  suggested  that  the  necessity  for 
allowing  escape  of  the  injected  fluid  has  been  only  recently  recognized, 
and  that  therefore  the  safety  of  the  method  has  been  only  of  late  secured ; 
but  this  is  not  so,  for  in  1833,  Melier,  of  France,  employed  a  double 
canula  constructed  on  the  same  principle  as  that  of  some  to  which  I  shall 
soon  make  allusion.  In  this  connection  it  may  not  be  unprofitable  to 
take  a  rapid  survey  of  the  history  of  the  subject.  For  most  of  my  facts  I 
am  indebted  to  an  exhaustive  article  by  Dr.  J.  Cohnheim,1  of  Berlin,  and 
translated  by  the  late  Dr.  Kammerer,2  of  this  city.  Intra-uterine  injec- 
tions were  employed  and  advised  *by  Hippocrates,  B.  C.  400,  for  the 
purposes  of  washing  out  bits  of  retained  placenta  and  medicating  the 
surface  affected  by  catarrh.  They  are  likewise  advised  by  Paulus  -iEgi- 
neta,  and,  as  we  come  down  to  later  times,  by  Sylvius,  Montanus,  Am- 
brose Pare,  Bottoni,  Roderic  a  Castro,  Mercurialis,  Ludovic  Mercatus, 
and  Astruc.  Otto,  a  translator  of  Astruc  into  German,  in  a  note  ex- 
presses the  opinion  that  the  fluid  does  not  ordinarily  penetrate  into  the 
uterine  cavity,  being  prevented  by  the  os  internum,  and  says  that  "  he 

1  Beitrage  zur  Therapie  der  Chronischen  Metritis.     Berlin,  1868. 

2  Amer.  Journ.  Obstet.,  vol.  i.  p.  377. 


302  CHRONIC    CORPOREAL    ENDOMETRITIS. 

knows  of  cases  in  which  the  use  of  the  above  'beautiful  remedies'  was 
followed  by  attacks  of  severe  uterine  colic."  The  method  was  again 
advised  by  Wenceslaus,  Collingwood,  Berends,  and  Steinburger,  and  op- 
posed with  apparently  equal  warmth  by  Frank  and  Hourmann.  The 
latter  author  drew  attention  to  the  dangers  of  the  method  by  reporting  a 
case  of  severe  metroperitonitis,  which  resulted  from  a  simple  injection 
given  for  leucorrhoea;  and  immediately  following  his  case  three  fatal  ones 
were  reported,  two  in  Bretonneau's  wards  and  one  in  Nelaton's.  At  a 
still  later  period  they  have  been  recommended  by  Reeamier,  Velpeau, 
Ricord,  Kennedy,  Retzius,  Routh,  Sigmund,  Matthews  Duncan,  Tilt, 
Braun,  Martin,  Courty,  Nott,  Kammerer,  and  others,  and  been  opposed 
by  Oldham,  Mayer,  Bessems,  H.  Bennet,  Gosselin,  Depaul,  and  others. 
Cases  of  violent  uterine  colic,  accompanied  by  great  prostration,  feeble 
and  rapid  pulse,  faintness  and  coldness  of  extremities,  are  repeatedly  re- 
corded even  by  the  advocates  of  the  method  ;  and  peritonitis,  ovaritis, 
and  salpingitis,  which  have  been  recovered  from,  have  been  met  with  as 
results  of  the  practice  by  Hourmann,  Leroy  d'Etiolles,  Landsberg,  Old- 
ham, Pedelaborde,  Retzius,  Becquerel,  Noeggerath,  myself,  and  others. 
Fatal  cases  of  peritonitis  have  occurred  to  Bretonneau,  Nelaton,  Gubiau, 
Noeggerath,  Von  Haselberg,1  Jobert,*  and  others.  A  case  of  sudden 
death  from  entrance  of  air  into  the  veins  has  been  met  with  by  Bessems,8 
who,  in  post-mortem  examinations,  "found  air-bubbles  in  the  vena  cava 
and  heart."  Another  case  ending  thus  suddenly  is  reported  by  Dr. 
"Warner,4  of  Boston,  as  occurring  at  the  Charity  Hospital  of  St.  Louis, 
where  "  a  small  quantity  of  water  injected  into  the  uterus  occasioned  im- 
mediately death.  This  result  was  evidently  from  shock."  I  do  not  find 
any  statistical  records  from  Dr.  Simpson  upon  the  subject,  but  the  general 
impression  left  upon  his  mind  concerning  the  method  is  thus  plainly 
stated  :*  "  But,  mark  you,  never  think  or  dream  of  throwing  liquids  into 
the  interior  of  the  uterus  by  means  of  any  injecting  apparatus,  for  severe 
and  fatal  inflammations  are  very  likely  to  ensue.  Such  a  result  may 
perhaps  be  caused  by  the  fluid  running  along  one  or  other  patent  Fallopian 
tube,  and  escaping  into  the  peritoneum  ;  more  probably  it  may  be  due  to 
laceration  of  the  mucous  membrane  and  entrance  of  the  fluid  into  one  of 
the  uterine  veins  ;  but  however  it  may  be  produced,  the  consequences  of 
injecting  fluid  into  the  cavity  of  the  womb  are  so  often  dangerous  and 
deadly,  that  the  practice  has  now  been  given  up,  I  believe,  by  all  accou- 
cheurs." In  this  passage  he  alludes  to  injections  into  the  non-puerperal 
uterus  for  dysmenorrhea.     Becquerel6  reports  the   practise  as  applied  to 

'  Amer.  Journ.  Med.  Sci.,  April,  1870,  p.  566. 

2  Bennet  on  the  Uterus,  p.  287. 

3  N.  Y.  Journ.  Obstet.,  vol.  i.  p.  394. 

4  Boston  Gynecological  Journal,  vol.  ii.  p.  286. 

6  Dis.  of  Women,  Am.  ed.,  p.  110.  6  Mai.  de  l'Cte'rus. 


INJECTIONS    INTO    THE    UTERINE    CAVITY.  803 

six  cases  of  uterine  catarrh.  "  In  one  case  only,  the  catarrh  was  dimin- 
ished; of  the  remaining  five,  three  could  be  saved  onty  by  energetic 
antiphlogistic  treatment,  the  effects  of  the  injection  being  exceedingly 
severe."  Noeggerath  reports  four  cases  treated  by  injections ;  in  the 
first  case,  cure  was  happily  effected  ;  in  the  second,  cure  was  accomplished, 
but  serious  and  protracted  symptoms  followed ;  in  the  third  case,  metro- 
peritonitis was  set  up,  but  controlled ;  and  in  the  fourth  case  the  patient 
died. 

There  are  two  considerations  in  connection  with  this  subject  which 
must  not  be  lost  sight  of.  One  of  them  is  thus  stated  by  Dr.  Henry 
Bennet :  "  This  accident"  [fatal  peritonitis,  due,  as  he  thought,  to  pas- 
sage of  fluid  through  the  Fallopian  tubes]  "would  probably  have  occurred 
much  oftener  than  it  has  done  in  the  hands  of  French  practitioners,  were 
it  not  that  the  natural  coarctation  of  the  os  internum  must  have  generally 
prevented  the  fluid  injected  from  penetrating  into  the  uterine  cavity." 
The  other  is  this,  that  many  cases  of  peritonitis,  some  fatal  and  others  not 
so,  which  have  been  due  to  it  have  not  been  reported.  One  of  the  former 
and  two  of  the  latter  have  come  to  my  own  knowledge. 

The  explanation  formerly  given  of  the  accidents  which  may  follow  this 
procedure,  was  very  naturally  the  penetration  of  fluid  through  the  Fallo- 
pian tubes  into  the  peritoneum.  But,  although  this  does  occasionally 
occur  (see  Von  Haselberg's  case  as  an  example),  it  has  been  proved  by 
experiment  upon  the  dead  body,  as  well  as  by  observation  of  the  practice 
upon  the  living,  that  there  is  a  resistance  on  the  part  of  the  tubes  which 
ordinarily  prevents  it.  Experiments  to  test  this  matter  have  been  care- 
fully conducted  by  Vidal,  Klemm,  and  Hennig,  and  all  with  the  same 
result.  It  is  probable  that  entrance  is  resisted  successfully  by  tubes  which 
are  healthy,  but  that  dilatation  and  atony  from  salpingitis  would  render 
the  patient  liable  to  the  accident. 

The  deduction  which  the  evidence  elicited  forces  upon  us  is  self-evident, 
namely,  that  at  the  same  time  that  this  method  of  treatment  systemati- 
cally and  carefully  resorted  to  is  a  valuable  resource  in  endometritis,  it  is 
attended  by  many  and  great  dangers.  While  it  is  proved  that  with  cer- 
tain precautions,  and  in  the  hands  of  one  skilled  in  manipulations  of  this 
character,  intra-uterine  injections  may  usually  be  employed  with  safety 
and  profit,  it  is  equally  manifest  that  a  certain  number  of  deaths  have 
been  due  to  them,  and  that  they  are  frequently  followed  by  excessive  pain 
and  grave  constitutional  symptoms  when  the  essential  precautions  are 
neglected.  I  should  strongly  recommend  the  general  practitioner  who  is 
unfamiliar  with  the  treatment  of  uterine  disorders  to  avoid  their  use 
entirely,  except  in  cases  of  uncontrollable  hemorrhage,  in  which  the  cervix 
is  well  dilated  and  no  flexure  of  the  uterus  exists.  When  he  is  induced 
to  essay  this  plan  in  the  treatment  of  corporeal  endometritis,  let  him  bear 


304  CHRONIC    CORPOREAL    ENDOMETRITIS. 

in  mind  that  the  possibility  of  easy  escape  of  the  fluid  injected  is  not  an 
advantage  merely,  but  an  essential  for  safety. 

One  very  recent  advocate  of  intra-uterine  injections  with  a  great  deal 
of  naivete  makes  the  following  statement : — ' 

"  Though  most  frequently  women  do  not  suffer  any  pain  when  injections, 
even  of  a  strong  solution  of  caustic,  are  made  into  the  womb,  yet  it  some- 
times happens  that  symptoms  which  give  great  alarm  to  inexperienced 
persons  do  occur.  The  patient  suddenly  cries  out,  complains  of  violent 
colics,  of  pain  in  the  womb  like  that  of  labor ;  the  abdomen  becomes 
swollen,  the  face  becomes  pale,  the  extremities  cold,  the  pulse  small,  and 
the  patient  is  thrown  into  a  state  of  great  depression.  These  symptoms 
arc  sometimes  accompanied  with  great  trembling  of  the  limbs  and  vomiting. 

"  I  have  related  a  case  of  this  kind  at  the  end  of  this  memoir.  Such  a 
train  of  symptoms  is  undoubtedly  alarming  in  appearance,  but  is  not  fol- 
lowed by  any  fatal  result." 

I  confess  to  sharing  the  feelings  of  those  inexperienced  persons  who  are 
greatly  alarmed  at  the  development  of  "  such  a  train  of  symptoms,"  for 
that  it  is  alarming  not  only  in  appearance,  has  been  more  than  abundantly 
proved  by  the  occurrence  of  death  in  a  number  of  cases. 

The  experiments  of  Vidal,  Hennig,  and  Klemm  force  us  to  admit  that 
passage  of  fluid  through  the  Fallopian  tubes  is  not  as  likely  an  occurrence 
from  intra-uterine  injections  as  one  would  suppose  it  would  be  from  theo- 
retical reasoning.  Cohnheim,  to  whose  admirable  resume  of  this  subject 
I  am  so  much  indebted,  appears  to  regard  them  as  conclusive.  To  my 
mind  they  are  very  far  from  being  so.  It  is  important  to  note  that  ex- 
periments performed  on  the  cadaver  are  usually  applied  to  healthy  uteri 
and  undilated  tubes,  while  the  gynecologist  employs  these  injections  in 
cases  where  the  endometrial  mucous  membrane  is  inflamed,  and  the  Fal- 
lopian tubes  very  often  dilated  in  consequence.  Is  it  not  likely  that  a 
disease  which  overcomes  the  sphincteric  action  of  the  os  internum  uteri 
would  likewise  have  a  similar  effect  upon  that  of  the  metro-salpingian 
orifices?  Post-mortem  examination  proves  this  to  be  the  case.  Then 
there  are  a  number  of  cases  on  record  in  which  such  immediate  inflamma- 
tory results  followed  in  the  peritoneum,  that  there  can  be  little  doubt  as  to  the 
occasional  relation  as  cause  and  effect.  Take  for  example  the  report  of  a 
case  by  Pedelaborde,  in  L'Union  Medicale  for  1850,  in  which,  "  three  min- 
utes after  an  injection  of  a  decoction  of  walnut  leaves,  severe  uterine  pains 
ensued,  and  in  a  few  hours  were  followed  by  acute  peritonitis."  A  similar 
instance  occurred  to  myself  from  injection  of  solution  of  persulphate  of 
iron.  Lastly,  in  a  fatal  case  occurring  to  Von  Haselberg,  the  metal  iron 
was  detected  by  chemical  tests  in  one  tube.  If  in  a  uterus  free  from  dis- 
ease, whether  in  the  cadaver  or  the  living  subject,  a  syringe  be  carried  up 

1  Gantillou  on  Uterine  Catarrh,  pamphlet,  1871. 


INJECTIONS    INTO    THE    UTERINE    CAVITY.  305 

to,  but  not  through,  the  os  internum,  and  an  injection  made,  the  fluid 
will  not  enter  the  cavity  of  the  body — and  why  ?  Because  corporeal  en- 
dometritis has  not  destroyed  sphincteric  action  at  the  os  internum.  But 
in  cases  of  endometritis,  where  that  action  is  destroyed,  a  paralyzation 
having  been  effected  there  by  disease,  how  different  is  the  case!  Under 
such  circumstances  patients  are  often  unable  to  use  vaginal  injections,  for 
the  reason  that  the  fluid  at  once  passes  into  the  cavity  of  the  body,  and 
produces  violent  uterine  colic. 

These  cases  are,  I  claim,  precisely  parallel,  and  ignoring  the  fact  upon 
which  I  have  here  laid  so  much  stress  is  not  only  invalidating  experiments 
made  to  throw  light  on  a  point  of  clinical  importance  ;  it  is  absolutely 
perverting  them  to  the  production  of  evil. 

The  medicinal  substances  which  have  been  thus  employed  have  varied 
very  much  with  the  views  of  different  practitioners.  Velpeau  employed 
concentrated  solutions  of  nitrate  of  silver  ;  Ricord  from  two  to  three  parts 
of  tincture  of  iodine  to  one  hundred  parts  of  water ;  Evory  Kennedy 
twenty  to  thirty  drops  of  nitrate  of  mercury  ;  while  Sigmund  resorts  to 
solutions  consisting  of  half  a  drachm  of  nitrate  of  silver,  one  drachm  of  sul- 
phate of  copper,  one  drachm  of  iodide  of  potassium  with  nine  grains  of 
iodine,  two  drachms  of  chloride  of  zinc,  or  three  drachms  of  perchloride 
of  iron,  to  three  ounces  of  water.  Hennig  employs  pure  warm  water  for 
a  time,  then  water  slightly  tinctured  with  iodine,  and  lastly,  pure  tincture 
of  iodine  or  solutions  of  silver ;  Fiirst,  one  drachm  of  nitrate  of  silver  to 
two  of  water ;  Martin,  of  Berlin,  five  grains  of  aluminate  or  sulphate  of 
copper  to  six  ounces  of  distilled  water;  and  Kammerer  used  ten  to  twenty 
drops  of  concentrated  solution  of  chromic  acid  ;  Lugol's  solution  of  iodine 
and  iodide  of  potassium,  or  pyroligneous  acid,  in  weak  solution  ;  or  ten 
grains  of  sulphate  of  zinc  to  one  ounce  of  water. 

Before  leaving  this  subject  I  will  embody  in  a  series  of  propositions 
the  most  important  facts  connected  with  it. 

1.  Intra-uterine  injections  may  produce  death  even  when  simple  and 
unirritating  fluids  are  employed,  by  peritonitis  due  to  absorption  of  the 
fluid  and  subsequent  phlebitis  ;  passage  of  fluid  into  the  peritoneum ;  en- 
dometritis (?) ;  or  by  sudden  entrance  of  air  into  a  vein. 

2.  Even  when  no  such  dire  result  takes  place,  they  may  set  up  severe 
uterine  colic,  with  tendency  to  collapse,  from  hysterical  neuralgia,  violent 
uterine  contractions  like  "after-pains,"  or  intense  irritation  of  uterine  and 
tubal  mucous  membrane. 

o.  These  dangers  may  be  to  a  great  extent  avoided  by  attention  to 
certain  rules,  which  here  follow  : — 

a.  Never  inject  the  uterine  cavity  except  with  the  certainty  that  the 
injected  fluid  can  rapidly  escape.  Therefore  always,  unless  the  os  inter- 
num be  very  much  dilated,  precede  the  injection  by  use  of  a  tent,  and 
always  use  a  syringe  insuring  immediate  reflux.  The  method  for  employ- 
20 


306  CHRONIC    CORPOREAL    ENDOMETRITIS. 

ing  uterine  injections  is  very  simple,  but  should  always  be  practised  with 
great  system  and  caution.  A  single  tube  of  silver  or  elastic  material  like 
a  catheter,  with  eyes  at  the  side,  may  be  used,  provided  the  little  syringe 
which  projects  the  fluid  be  immediately  removable  so  that  the  means  of 
ingress  may  at  once  become  the  means  of  egress.  "We  may,  however,  still 
more  certainly  insure  egress  by  another  instrument.  The  necessity  for 
return  of  the  injected  fluid  is  so  great  that  canulse  with  double  canals  or  a 
canal  and  gutter  have  been  constructed  with  especial  reference  to  this. 
One  of  the  most  effectual  and  safest  of  these  is  the  instrument  shown  in 
Fig.  121. 

Fig.  121. 


Molesworth's  double  canula  and  bulb  syringe  for  injecting  the  uterine  cavity. 

"When  the  India-rubber  bulb  is  squeezed,  the  fluid  which  it  contains 
escapes  from  holes  in  the  end  of  the  canula,  and  at  once  returns  through 
another  tube  which  lies  alongside  of  it.  Then,  as  the  compression  of 
the  bulb  ceases,  a  vacuum  is  created  which  sucks  back  every  superfluous 
drop. 

b.  The  best  substances  for  injection  are  tincture  of  iodine,  nitrate  of 
silver,  sulphate  of  soda,  pyroligneous  acid,  carbolic  acid,  and  sulphates  of 
zinc,  copper,  or  iron  in  weak  solution.  It  is  best  always  to  begin  with 
the  use  of  weak  alkaline  injections  of  warm  water,  not  only  to  see  how 
tolerant  the  uterus  will  prove  to  the  process,  but  because  in  the  experi- 
ments of  Klemm  on  the  cadaver,  in  three  out  of  eighteen  cases,  blue  ink 
injected  through  a  narrow  os  with  moderate  force  penetrated  the  venous 
system  of  the  uterus  and  broad  ligaments  without  apparent  laceration. 
After  tolerance  has  been  tested,  stronger  solutions  may  be  used. 

c.  Always  use  solutions  at  a  temperature  of  at  least  85°  to  90°. 

d.  Wash  out  the  cavity  with  warm  fluid  before  using  the  stronger  ap- 
plication; and  in  injecting  always  be  sure  that  there  is  no  air  in  the 
syringe,  and  never  eject  the  fluid  which  it  contains  with  force. 

e.  Never  employ  this  method  in  a  sharply  flexed  uterus  before  replace- 
ment, never  just  before  or  after  a  menstrual  period,  and  never  when  pelvic 
peritonitis  or  periuterine  cellulitis  has  recently  existed. 

/.  After  the  use  of  this  plan  let  the  patient  lie  down  until  all  sense  of 
discomfort  has  passed,  and  confine  her  to  bed  and  give  opium  freely  on 
the  first  appearance  of  pain. 

4.  In  uterine  colic  the  most  certain  and  immediate  relief  will  follow 
the  use  of  morphia  by  the  hypodermic  syringe.  Astruc  advised  the  addi- 
tion of  narcotics  to  injected  solutions  for  the  prevention  of  the  accident. 


AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS.  307 

5.  Lastly,  although  this  plan  of  treatment,  robbed  of  many  of  its  dan- 
gers by  the  precautionary  measures  here  advised,  may  be  comparatively 
safe  in  the  hands  of  specialists  skilled  in  uterine  manipulations,  it  will 
always  remain  a  hazardous  method  for  the  general  practitioner  who 
lacks  such  skill  and  who  employs  instruments  not  entirely  suited  to  the 
purpose. 

It  may  now  be  asked,  since  I  oppose  the  habitual  practice  of  carrying 
applications  above  the  os  internum  uteri  as  well  as  that  of  injecting  the 
uterine  cavity,  what  course  I  do  advise  and  adopt  in  the  management  of 
this  affection.  As  I  have  already  stated,  I  would  recommend  careful 
attention  to  the  general  state,  removal  of  displacements,  cure  of  lacera- 
tion of  the  cervix,  extirpation  if  possible  of  any  existing  neoplasm,  and, 
if  uterine  enlargement  exist,  the  free  use  of  ergot.  To  favor  the  free 
escape  of  mucus  from  the  uterine  cavity  I  would  see  that  the  cervical 
canal  be  dilated.  And  now  if  improvement  did  not  occur  I  would  apply 
the  dull  wire  curette  freely  over  the  whole  surface.  In  speaking  of  the 
pathology  of  corporeal  endometritis,  it  was  stated  that  the  diseased  mem- 
brane in  time  develops  upon  its  surface  fungoid  granulations,  mucous 
cysts,  and  mucous  polypi.  These  secondary  conditions  often  result  in 
metrorrhagia  or  menorrhagia.  Not  only  does  the  gentle  application  of  the 
little  wire  curette  without  cutting  edge  accomplish  the  removal  of  these, 
it  produces,  when  thoroughly  applied,  an  altered  state  in  the  entire  en- 
dometrial membrane,  breaks  distended  bloodvessels,  and  often  accomplishes 
a  great  deal  for  the  relief  of  the  disease.  In  cases  of  endometritis  engrafted 
upon  subinvolution  and  accompanied  by  hemorrhage,  it  is  especially  ap- 
plicable. But  its  beneficial  results  depend,  I  feel  sure,  upon  the  fracture 
of  tortuous  and  distended  bloodvessels,  and  it  is  chiefly  for  this  purpose 
that  I  use  it. 

The  use  of  the  dull  wire  curette  does  a  greater  amount  of  good  in  these 
cases  at  the  expense  of  less  risk  than  the  applications  just  mentioned,  and 
I  infinitely  prefer  it. 


CHAPTER   XX. 

AREOLAR  HYPERPLASIA  OF   THE  UTERUS— THE  SO-CALLED  CHRONIC 
PARENCHYMATOUS  METRITIS. 

Definition  and  Nomenclature One  of  the  most  common  pathological 

combinations  which  confronts  the  gynecologist  is  that  which  I  here  en- 
deavor in  as  concise  a  manner  as  possible  to  picture.     A  patient  calls  upon 


308  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

him  for  relief  of  backache ;  pelvic  pains ;  dragging  sensation  about  the 
loins  ;  "  bearing-down  pains  ;"  leucorrhcea  ;  menstrual  disorder,  tending 
chiefly  to  excessive  flow;  throbbing  sensation  about  the  uterus;  general 
feeling  of  despondency  ;  malaise  and  weakness  ;  and  irritability  about  the 
bladder  and  rectum.  All  these  rational-  signs  pointing  to  the  uterus 
as  the  probably  delinquent  organ,  a  physical  exploration  is  made,  and 
furnishes  the  following  results:  the  uterus  is  usually  discovered  to  be  in 
the  condition  of  descent,  retroflexion,  or  anteflexion ;  it  is  voluminous, 
tender  to  the  touch,  and  evidently  engorged  with  blood;  from  the  cervical 
canal  a  leucorrhceal  matter  pours;  the  probe  carried  to  the  fundus  finds 
it  tender,  and  creates  the  flow  of  a  little  blood;  the  cervix  is  often  ki  a 
condition  of  granular  or  cystic  degeneration  ;  and  a  low  grade  of  vaginitis 
exists. 

To  this  pathological  combination  the  more  superficial  diagnostician  will 
often  apply  a  name  which  announces  one  only  of  the  existing  conditions; 
as,  for  example,  uterine  catarrh,  ulceration  of  the  cervix,  or  retroversion 
or  prolapse.  The  more  reflective  and  intelligent  examiner  will  ordinarily 
group  the  coincident  morbid  states  together  under  the  name  of  "  chronic 
metritis." 

The  latter  would  be  fully  sustained  in  his  position  by  authority  as  abun- 
dant as  it  is  orthodox,  for  by  systematic  writers,  since  the  days  of  Reca- 
mier,  this  uterine  state. has  been  described  as  one  of  "chronic  parenchy- 
matous metritis."  Only  within  a  very  recent  period  have  the  pathologists 
of  the  German  school  begun  to  question  the  validity  of  this  conclusion, 
which,  taking  its  origin  in  France,  was  spread  through  England  and 
America  chiefly  by  the  writings  of  Dr.  Henry  Bennet.  According  to  this 
view  the  following  pathological  changes  were  believed  to  be  those  resulting 
in  the  condition  just  described.  In  the  first  stage  the  parenchyma  was 
regarded  as  gorged  with  blood,  a  state  of  active  congestion  existing.  This 
was  supposed  soon  to  pass  into  the  second  stage,  consisting  in  an  effusion 
of  lymph,  when,  unlike  a  similar  process  in  other  parts,  the  morbid  action 
ceased,  or  rather  did  not  advance,  and  unless  relieved  by  treatment,  con- 
tinued stationary  for  a  length  of  time.  The  third  stage  of  inflammation 
in  other  parts,  that  of  suppuration,  was  admitted  to  occur  rarely  here,  or 
in  the  parenchyma  of  the  body,  but  in  time  all  inflammatory  action  ceas- 
ing, the  cervix  remained  large  and  indurated  without  sensitiveness,  or  the 
effused  lymph  might  be  absorbed,  and  great  diminution  in  size  occur  with 
induration.  Were  this  really  the  case  the  condition  would  constitute  one 
of  inflammation,  even  if  we  restricted  ourselves  in  the  use  of  that  ambigu- 
ous term  to  the  narrow  and  precise  limits  prescribed  by  Dr.  J.  Hughes 
Bennett,  when  he  says,  "  It  should  be  applied  only  to  that  perverted  alte- 
ration of  the  vascular  tissues,  which  produces  an  exudation  of  the  liquor 
sanguinis ;  it  is  this  exudation  alone  which  can  be  held  to  unequivocally 
characterize  an  inflammation." 


AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS.         309 

Examined  more  recently,  however,  by  the  more  certain  and  less  theo- 
retical processes  of  modern  science,  all  this  has  come  to  be  looked  upon 
as  erroneous.  Cases  which  were  formerly  regarded  as  instances  of  inflam- 
mation on  account  of  the  existence  of  enlargement,  congestion,  and  tender- 
ness upon  pressure,  the  microscope  now  proves  to  have  been  instances  of 
excessive  growth  of  the  connective  tissue  of  the  uterus,  with  congestion, 
and  resulting  hyperesthesia  of  its  nerves. 

It  may  result  from  three  entirely  different  pathological  states  :  first,  from 
interference  with  retrograde  metamorphosis  of  the  puerperal  uterus  from 
any  cause;  second,  from  congestion  long  kept  up  by  mechanical  causes, 
such  as  displacement ;  third,  from  a  formative  irritation  or  state  of  hyper- 
nutrition  excited  by  endometritis,  or  the  existence  of  fibrous  tumors. 
Whatever  be  the  originating  pathological  condition,  that  which  results  and 
which  we  are  now  considering  consists  in  hyperplasia  of  connective  tissue 
as  its  most  marked  feature,  and  of  congestion  and  nervous  hyperesthesia 
as  important  accompaniments. 

It  is  true  that  some  progressive  writers  still  cling  to  the  name  chronic 
inflammation,  and  apply  it  to  hyperemia  resulting  in  hypergenesis  or  hy- 
pertrophy of  connective  tissue,  but  this  is  by  no  means  the  signification 
which  is  ordinarily  given  to  the  term.  Indeed,  with  reference  to  the  ute- 
rus, so  vague  and  unsatisfactory  is  the  appellation  chronic  metritis,  that 
there  is  no  knowing  what  idea  one  who  uses  it  really  intends  to  convey. 
He  who  has  in  the  library  and  at  the  bedside  been  perplexed  and  dis- 
heartened by  the  constantly  recurring  uncertainty  which  it  has  induced, 
will  have  learned  to  appreciate  the  feeling  which  prompted  two  eminent 
pathologists,  Andral  and  J.  Hughes  Bennett,  to  propose  that  the  vague 
term  "  inflammation"  should  be  expunged  from  our  nomenclature.  To 
quote  the  words  of  an  accomplished  writer  of  this  city: — 

"  The  entity  inflammation,  fallen  from  its  high  and  palmy  state,  is 
hanging  by  its  eyelids  as  a  pathogenic  factor  in  most  of  the  organs  of  the 
body ;  its  last  resting  place  seems  to  be  the  womb,  and  here  still  it  has  a 
good  foothold.  Why  should  uterine  pathology  alone  be  cumbered  by  an 
outworn  theory?" 

It  is  not  an  entirely  correct  statement  that  this  pathological  doctrine 
originated  in  France.  Upon  the  revival  of  gynecology  in  that  country  by 
the  labors  of  Eecamier,  it  likewise  revived  and  assumed  important  pro- 
portions. But  the  theory  of  parenchymatous  inflammation  as  explaining 
this  condition  is  as  old  as  the  science  of  medicine  itself,  and  it  certainly  is 
a  peculiar  commentary  upon  it,  that  now,  in  the  most  advanced  period 
that  the  science  has  ever  known,  the  retention  of  it  not  only  results  in 
doubt,  uncertainty,  and  scepticism,  but  absolutely  creates  controversial 
discussion,  and  forms  sects  and  factions,  where  all  should  be  united  for  the 
common  good.  "  All  must  mourn,"  remarked  the  late  Professor  Hodge, 
"  over  a  discrepancy  of  opinion  which  bears  so  directly  on  the  treatment 


310         AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

of  such  painful  and  distressing  maladies."  "  We  cannot  but  believe," 
says  Meredith  Clymer,  "  that  the  time  is  not  far  off  when  this  vexed  but 
important  question  will  be  re-opened,  and  examined  in  a  fair-judging,  and 
not  peremptory  and  dogmatic  spirit,  uninfluenced  by  prejudice,  prescrip- 
tion, or  tradition ;  and  that,  measured  by  a  new  standard,  and  settled  by 
the  requirements  of  a  more  enlightened  knowledge  of  the  laws  of  life, 
present  differences  will  be  reconciled,  hostile  opinions  conciliated,  and  the 
angry  voice  of  adverse  factions  be  heard  '  not  any  more  forever.'  " 

Everywhere  throughout  the  recent  and  progressive  literature  of  gyne- 
cology, the  foreshadowing  of  the  advancing  change  in  views  with  regard 
'  to  this  subject  will  be  recognized.  The  pendulum,  swung  too  far  by  the 
hand  of  Dr.  Henry  Bennet,  is  making  its  inevitable  return.  That  it 
may  stop  on  safe  middle  ground  must  be  the  hope  of  all.  "  The  determi- 
nation of  blood  to  a  part  here  noticed,  characterized  by  dilatation  of  the 
arteries,  with  increased  flow  of  blood  through  the  capillaries,  must  be  dis- 
tinguished from  the  congestion  of  inflammation,  characterized  by  the 
accumulation  and  stagnation  of  red  and  white  corpuscles  in  the  vessels, 
tending  to  be  abnormally  adherent  to  each  other  and  to  the  vessels,"  says 
Dr.  H.  G.  "Wright,1  quoting  from  Dr.  Aitken.  "  Tested  by  this  standard," 
that  of  Dr.  J.  Hughes  Bennett,  already  quoted,  says  Dr.  Graily  Hewitt,2 
"  the  uterus  is  certainly  very  little  liable  to  '  inflammation ;'  exudation, 
and  transformations  of  such  exudations,  purulent  and  otherwise,  similar  to 
what  may  be  witnessed  in  other  organs  of  the  body,  being  very  rarely 
witnessed  in  the  parenchyma  of  the  uterus.  The  morbid  processes  with 
which  we  are  familiar  as  affecting  the  tissues  of  the  uterus  are  for  the  most 
part  alterations  of  growth,  irregularities  in  growth,  slight  modifications,  in 
fact,  of  the  processes  which  follow  each  other  in  due  succession  in  the 
natural  condition  of  things.  The  word  '  inflammation,'  used  in  Dr.  J. 
Hughes  Bennett's  sense  of  the  word,  certainly  fails  to  convey  an  adequate 
idea  of  the  modifications  observed  under  such  circumstances."  "  Diffuse 
growth  of  connective  tissue,"  says  Klob,3  "  constitutes  the  so-called  indu- 
ration, hitherto  considered  as  a  result  of  parenchymatous  inflammation  of 
the  uterus.  .  .  .  For  reasons  mentioned,  I  would  also  advise  a  disuse 
of  the  term  '  chronic  inflammation.'  "  In  a  discussion*  upon  chronic 
metritis  before  the  New  York  Academy  of  Medicine,  Dr.  Noeggerath 
limited  the  disease  to  "growth  of  the  cellular  tissue  both  of  the  body  and 
neck,  occurring  only  during  the  puerperal  state."  Dr.  Peaslee  preferred 
"  to  call  the  disease  under  consideration  congestion,  rather  than  inflamma- 
tion, because  it  has  none  of  the  events  of  inflammation  ;"  and  Dr.  Kam- 
merer  expressed  the  view  that  "  chronic  inflammation  of  the  substance  of 
the  non-puerperal  uterus  is  never  met  with  ;  what  has  been  described  as 

1  Uterine  Disorders,  p.  218.  2  Dis.  of  Women,  p.  363. 

»  Op.  cit.,  p.  129.  *  Med.  Record,  No.  92,  p.  475. 


AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS.  311 

such  is  hypertrophy  of  connective  tissue,  resulting  from  long-continued 
hyperaemia." 

These  views,  which  among  men  who  are  in  the  advance  in  gynecology 
are  rapidly  gaining  ground,  are  not  sustained  by  analogical  reasoning,  but 
by  anatomical  proof.  I  know  of  nothing  which  will  more  surely  convince 
the  reader  of  the  necessity  for  an  alteration  in  our  nomenclature  concern- 
ing this  condition,  than  a  perusal  of  Scanzoni's1  article  upon  it.  This 
author,  after  heading  his  chapter,  "  Chronic  Parenchymatous  Inflammation 
of  the  Womb,"  goes  on  to  say  :  "  The  nature  of  the  disease  would  then 
be,  in  an  anatomical  point  of  view,  an  hypertrophy  of  the  cellular  tissue." 
Certainly  the  "  anatomical  point  of  view"  is  an  important  one,  and  it  is 
supported  by  what  we  observe  from  a  clinical  stand-point. 

So  much  evil  has  arisen  for  pathology  and  treatment  from  the  use  of  the 
term  chronic  metritis,  and  so  clear  a  demonstration  has  been  made  that 
the  condition  so  called  is  not  one  of  true  inflammation,  that  some  other  ap- 
pellation is  not  only  desirable,  but  has  become  absolutely  essential.  It  is 
incontestable  that  there  is  a  peculiar  condition  that  affects  the  uterus 
which  is  characterized  by  distention  of  bloodvessels  from  vital  or  mecha- 
nical cause  ;  effusion  of  the  serum  of  the  blood  ;  and  hypergenesis  of  con- 
nective tissue.  To  denote  this  state,  gynecologists  have  long  required  a 
name,  for  medical  nomenclature  is  as  necessary  as  it  is  faulty.  Lisfranc 
felt  this  need  when  he  styled  it  "  engorgement ;"  Hodge  when  he  entitled 
it  "  irritable  uterus  ;"  Bennet  when  lie  called  it  "  metritis  ;"  and  others 
also  have  acknowledged  the  necessity,  Klob,  for  example,  in  "  habitual 
hyperaemia"  and  "  diffuse  proliferation  of  connective  tissue,"  and  Kiwisch 
in  "  infarctus." 

The  appellations  infarctus,  engorgement,  and  hyperemia  only  convey 
a  partial  idea  of  the  truth  ;  they  only  announce  one  element  of  the  con- 
dition— congestion  ;  while  that  of  irritable  uterus  ignores  all  structural 
change  in  announcing  another  element — nervous  hyperesthesia.  At  the 
same  time  that  the  phrase  "  diffuse  proliferation  of  connective  tissue  due  to 
hyperemia, "  which  is  employed  by  Klob,  clearly  defines  the  pathological 
condition,  it  is  too  long  and  burdensome  to  answer  the  purpose  of  a  name 
to  be  conventionally  employed.  If  tiiere  be  a  term  now  in  existence  which 
does  really  convey  the  idea  truly  and  completely,  it  should  surely,  in  the 
interests  of  pathology  and  treatment,  as  well  as  out  of  consideration  for 
the  overburdened  student  of  medical  nomenclature,  be  employed  in  prefer- 
ence to  the  adoption  of  a  new  one.  Enlargement  of  an  organ  dtie  to  for- 
mation of  new  cells  similar  to  those  of  the  tissue  in  which  they  are  de- 
veloped, has  been  styled  by  Virchow,  hyperplasia,  in  contradistinction  to 
hypertrophy,  which  consists  in  increase  of  size  from  distention  of  cells 
already  existing.     As  the  condition  of  the  uterus  now  under  consideration 

1  Dis.  of  Females,  Am.  ed.,  p.  181. 


312  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

is  one  arising  from  over-excitation  of  the  vaso-motor  and  excito-nutritive 
nerves,  a  "  formative  irritation,"  as  Klob  styles  it,  and  resulting  in  a 
numerical  hypertrophy,  it  appears  to  me  that  the  term  areolar  hyperplasia 
would  more  correctly  designate  it  than  any  other  with  which  I  am  ac- 
quainted. With  a  sincere  desire  to  lessen  and  not  to  increase  the  labors 
of  the  student  and  the  perplexities  of  the  gynecologist,  I  shall  therefore 
replace  the  confusing  term  chronic  metritis,  by  that  of  areolar  hyperplasia 
of  the  uterus. 

That  the  term  is  faultless,  I  do  not  claim.  To  one  unaccustomed  to  it, 
it  must  even  appear  peculiar.  I  have  merely  to  ask  for  it  a  favorable 
consideration  on  the  grounds  that  it  is  faithfully  descriptive  of  the  condi- 
tion to  which  it  is  applied,  and  that  a  decided  necessity  for  some  such 
term  exists. 

In  a  very  fair,  critical  review1  of  the  third  edition  of  this  work,  the 
reviewer  remarks  that  this  name  "  involves  the  notion  that  the  connective- 
tissue  elements  alone  hypertrophy,  and  disowns  the  muscular  element  as 
the  one  most  readily  provoked  to  increase.  We  do  not  deny  that,  in  the 
disease  in  question,  there  is  hyperplasia  of  connective  tissue,  or,  at  any 
rate,  of  non-muscular  elements  ;  but  we  must  aver  our  belief  that  concomi- 
tantly there  is  increase  in  the  muscular  elements  also."  At  first  glance, 
this  appears  to  be  a  very  strong  point  of  objection  ;  but  I  think  that  even 
the  writer  himself  will,  upon  more  careful  examination  of  the  views  of 
pathologists,  agree  that  they  look  upon  the  proliferation  of  areolar  tissue 
as  always  the  characteristic  or  highly  predominant  feature  of  the  condition, 
and  regard  muscular  growth  as  an  insignificant  accompaniment  only. 
For  obvious  reasons  it  is  impossible  for  me  to  quote  largely  to  sustain  this 
position,  and  I  confine  myself  to  the  statement  of  Professor  Klob,2  who, 
in  speaking  of  this  condition,  expresses  himself  in  the  following  terms : 
"  The  whole  uterine  connective  tissue  sometimes  proliferates  either  with- 
out accompanying  increase  of  the  muscular  substance,  or,  if  this  does 
occur,  the  connective  tissue  predominates  to  such  an  extent  that  the  mus- 
cular substance  is  comparatively  of  not  much  account." 

It  is  true,  that,  while  most  who  have  investigated  this  subject  have 
found,  like  Klob  and  Scanzoni,  a  great  preponderance  of  connective  tissue, 
and  an  insignificant  increase  of  muscular  elements,  some  have  declared 
that  the  muscular  structure  is  greatly  hypertrophied.  One  reason  for  this 
variance  of  opinion  is  this  :  the  most  prolific  source  of  areolar  hyperplasia, 
the  so-called  chronic  metritis,  is  interference  with  involution  of  the  par- 
turient  uterus.  What  begins  as  subinvolution  ends,  in  time,  in  a  condi- 
tion   ordinarily    styled    chronic    metritis.     He  who  examines  early    will 

1  Brit,  and  Foreign  Medico-Chirurgieal  Rev.,  Jan.  1873. 

8  In  the  American  translation  of  Klob  the  rendering  is  not  this ;  hut  Dr. 
Kammerer.  the  translator,  informed  me  that  that  passage  is  not  correct,  but  that 

this  is. 


PATHOLOGY    OF    AREOLAR    HYPERPLASIA.  318 

probably  find  a  greater  amount  of  muscular  elements  than  he  who  docs  so 
later  ;  and  let  it  be  remembered  that  by  continental  writers,  with  one  ex- 
ception,1 no  recognition  is  made  of  subinvolution  as  a  disease  distinct  from 
what  Chomel  styled  it,  post-puerperal  metritis.  In  this  way  I  reconcile 
the  researches  of  Klob,  whose  statement  I  have  quoted,  with  those  of 
Finn,2  who  reports  the  following  observations,  made  at  the  Institute  of 
Pathological  Anatomy  in  St.  Petersburg  : — 

"  1.  The  normal  disposition  of  the  single  muscular  fibre,  as  wrell  as  of  the 
muscular  bundle,  remains  unchanged. 

"  2.  The  muscular  fibres  do  not  change  in  quality,  neither  is  their  fatty 
degeneration  a  pathognomonic  sign  of  this  disease. 

"3.  The  muscular  fibres  are  always  extended  in  both  their  length  and 
breadth  above  their  normal  standard,  but  more  so  in  the  former  direction. 

"4.  The  number  of  fibres  is  always  largely  increased. 

"o.  The  amount  of  connective  tissue  in  the  latter  stage  of  the  disease 
is  always  relatively  diminished,  but  absolutely  enlarged,  so  that  the  in- 
crease of  bulk  of  the  uterus  is  mainly  caused  by  the  hyperplasia  of  the 
muscular  fibres,  the  augmentation  of  the  connective  tissue  iulluencing  it 
but  little." 

If  the  disease  really  consists  in  a  proliferation  or  hypertrophy  of  the 
areolar  or  connective  tissue  of  the  uterus,  and  not  in  chronic  inflammation, 
it  would  certainly  be  advantageous  to  apply  to  it  some  name  which  would 
signify  that  fact.  "Areolar  hyperplasia" 3  expresses  this  fact  concisely, 
and  hence  I  have  employed  it. 

Pathology  of  Areolar  Hyperplasia — The  vast  majority  of  cases  are  due 
to  interference  with  that  retrograde  metamorphosis  occurring  in  the  puer- 
peral uterus,  styled  involution.  To  comprehend  the  pathology  of  cases 
thus  arising,  it  will  be  necessary  to  consider  the  physiology  of  that  process 
as  well  as  the  pathological  conditions  which  may  affect  it. 

It  is  only  within  the  last  quarter  of  a  century  that  we  have  understood 
the  process  by  which  the  uterus,  an  organ  measuring  three  inches,  in  the 
short  space  of  nine  months  enlarges  so  as  to  contain  a  child  or  even  two 
or  three  children,  and  then  within  two  months  after  delivery,  undergoes 
so  rapid  an  absorption  as  to  return  to  its  original  size.  The  credit  of 
elucidating  the  subject  belongs  chiefly  to  Germany,  for  it  is  to  Virchow, 
Franz  Kilian,  Ileschl,  Kolliker,  and  Retzius  that  we  are  most  indebted. 

The  important  pathological  fact  that  arrest  in  or  disturbance  of  this 
process  constitutes  a  condition  of  disease  emanated  from  Sir  James  Simp- 
son, who,  in  1852,  published  the  first  article  which  drew  especial  attention 
to  it.     His  article  was  entitled,  "  Morbid   Deficiency  and  Morbid  Excess 

>  M.  Courty.  2  Am.  Journ.  Obstet.,  vol.  i.  p.  264. 

3  Hypertrophy  signifies  excessive  growth  of  the  elements  of  a  tissue  already 
existing  ;  hyperplasia  signifies  the  development  of  new  tissue. 


314  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

in  the  Involution  of  the  Uterus  after  Delivery."  Since  that  time,  the 
condition  which  now  engages  us  has  become  generally  recognized  as  a 
uterine  state  of  great  frequency  and  moment. 

To  fully  comprehend  this  part  of  our  subject  it  is  necessary  to  bear  in 
mind  the  component  parts  of  the  healthy  uterine  parenchyma.  It  con- 
sists of  five  elements :  1st.  Fusiform  fibre  cells,  or,  as  they  are  termed, 
the  smooth  muscular  fibres ;  2d.  Round  and  oval  nuclei,  which  are  sup- 
posed to  be  elementary  fusiform  fibre  cells ;  3d.  Amorphous  or  homoge- 
neous connective  tissue,  which  permeates  the  parenchyma  and  bind3 
together  the  fibre  cells  and  nuclei  ;  4th.  Fibrillated  connective  tissue  or 
white  fibrous  tissue;  and  5th.  Elastic  fibrous  tissue.  These  elements, 
together  with  nerves,  bloodvessels,  and  lymphatics,  make  up  the  tissue  of 
the  uterus,  which  is  covered  by  a  serous  membrane  externally  and  a  mu- 
cous membrane  within. 

No  sooner  does  this  structure  feel  the  stimulus  of  conception  than  it 
develops  rapidly,  partly  by  growth  of  already  existing  structures  and 
partly  by  new  formations.  The  round  or  oval  nuclei  rapidly  develop  into 
fusiform  cells,  and  these  as  rapidly  grow  into  colossal  cells  which  grow 
longer  and  more  powerful  as  pregnancy  advances.  "A  new  formation  of 
muscular  fibre  also  takes  place,"1  the  connective  tissue  elements  grow 
proportionately,  and  the  bloodvessels  enlarge. 

Parturition  occurs,  and  almost  immediately  a  retrograde  evolution 
begins  to  restore  the  uterus  to  its  original  constituency.  The  fully  de- 
veloped fibres  undergo  a  fatty  degeneration  ;  the  fat  thus  formed  is  absorbed, 
and  the  organ  rapidly  diminishes  in  size  and  weight.  This  fatty  degen- 
eration affects  the  organ  after  the  fourth  day  subsequent  to  delivery,  and, 
according  to  Ileschl,  the  commencement  of  a  new  formation  of  muscular 
fibres  is  recognized  in  the  fourth  week  after  labor,  in  the  form  of  nuclei 
and  caudate  cells.  At  the  end  of  the  eighth  week  the  uterus  has  returned 
to  its  normal  state. 

Certain  untoward  influences  may  retard  or  check  this  process,  and  the 
uterus  remain  flabby  and  large,  when  it  is  said  to  be  in  a  state  of  subin- 
volution, or  arrested  retrograde  evolution. 

Thus  far  we  have  been  dealing  with  facts  thoroughly  ascertained  by 
histological  investigations  and  fully  established  by  evidence  yielded  by  the 
microscope.  But  from  this  point  the  pathology  of  subinvolution  is  not  so 
satisfactorily  settled.  Prof.  Simpson  declared  that  the  disease  was  due  to 
the  fact  that  "  this  retrograde  metamorphosis  of  the  uterus  has  not  taken 
place  during  the  puerperal  month,  or  has  taken  place  only  to  such  an 
imperfect  degree  that  the  uterus  is  of  the  size  we  usually  see  it  have  at 
the  end  of  the  first  week  or  so  after  delivery ;"  but  he  entered,  if  I  may 
judge  from  the  posthumous  volume  of  his  work  upon  Diseases  of  Women, 

1  Arthur  Farre,  Cyc.  Anat.  and  Phys.,  article  Uterus. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.        315 

upon  no  detailed  account  of  the  existing  pathological  defect  in  the  organ. 
Since  his  writing,  it  appears  to  have  been  agreed  upon  that  this  consists 
of  persistence  of  the  muscular  fibres,  characterizing  pregnancy,  in  a  state 
of  fatty  degeneration.  Thus  Dr.  Wright1  says,  "  Pathologically  it  closely 
corresponds  with  that  state  of  the  heart  structure  so  admirably  described 
by  Dr.  Richard  Quain,  and  commonly  known  as  fatty  degeneration." 
Dr.  West2  expresses  himself  thus  :  "  Though  fatty  degeneration  of  the 
tissues  takes  place,  yet  the  removal  of  the  useless  material  is  but  imper- 
fectly accomplished,  while  the  elements  of  the  new  uterus  are  themselves, 
as  soon  as  produced,  subjected  to  the  same  alteration."  I  search  in  vain 
the  literature  of  the  pathology  of  this  subject  for  a  basis  for  these  hypo- 
theses. That  literature  is  scanty  in  the  extreme  as  yet,  and  the  subject 
awaits  extended  researches  before  we  can  speak  intelligently  of  it.  The 
day  has  passed,  however,  when  we  can  let  probabilities  in  pathology  pass 
current  for  facts. 

The  best,  indeed  I  may  say  the  only  detailed  account  of  this  condition 
studied  by  the  microscope,  which  I  have  been  able  to  obtain,  is  one  by 
Dr.  Snow  Beck,3  of  London.  "The  enlargement  of  the  uterus  did  not 
depend  so  much  upon  an  increase  in  the  size  of  the  contractile  fibre-cells, 
as  upon  an  increased  amount  of  round  and  oval  globules,  with  amorphous 
tissue  in  the  uterine  walls.  .  .  .  The  essential  condition  of  the  organ 
consisted  in  the  elements  of  the  different  tissues  retaining  a  portion  of  the 
natural  enlargement  consequent  upon  impregnation.  But  this  enlarge- 
ment was  more  due  to  the  increased  size  and  amount  of  the  soft  tissue 
present  in  the  walls  of  the  uterus,  as  well  as  at  the  internal  surface,  than 
to  the  increased  size  of  the  contractile  fibre-cells."  Marked  congestion 
existed,  the  bloodvessels  being  large  and  forming  a  complete  and  continuous 
system  with  the  capillary  network  on  the  inner  surface  of  the  uterus.  No 
allusion  to  preponderance  of  muscular  fibres  is  anywhere  made,  and  no 
mention  of  fatty  degeneration  occurs. 

The  condition  of  the  uterine  cavity  is  important.  It  is  always  increased 
in  size,  the  glands  of  the  cervix  are  usually  enlarged,  and  upon  the  lining 
membrane  of  the  cavity  fungoid  growths  are  commonly  developed. 

This  is  all  that  can  with  positiveness  be  said  of  the  pathology  of  the 
early  periods  of  subinvolution  in  the  present  undeveloped  state  of  the 
subject. 

The  uterus,  the  study  of  the  tissues  of  which  gave  Dr.  Beck's  results, 
measured  3^  inches  in  length,  2^  inches  across  the  fundus,  the  walls  were 
If  inches  thick,  and  the  uterine  canal  was  3  inches  deep. 

As  time  passes  the  uterine  walls  diminish  in  size,  their  tissue  grows  less 

1  Uterine  Disorders,  p.  221. 

2  Dis.  of  Women,  3d  Eng.  ed.,  p.  89. 

3  London  Obstetrical  Trans.,  vol.  xiii.  p.  239. 


316  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

vascular,  the  bloodvessels  become  smaller,  and  the  uterine  cavity  assumes 
smaller  dimensions.  But  the  organ  does  not  assume  its  original  size;  it 
remains  large,  dense,  firm,  and  sensitive ;  for  years  presenting  the  charac- 
teristic appearances  of  the  so-called  chronic  parenchymatous  metritis. 
Although  taking  an  entirely  different  view  of  the  pathology  of  chronic 
metritis,  Dr.  "West1  signalizes  almost  the  same  fact  in  the  following  words: 
"  It  must,  however,  be  at  once  apparent,  that  after  inflammation  has  passed 
away,  its  effects  may  remain  in  the  larger  size  and  altered  structure  of  the 
womb,  and  that  the  very  nature  of  these  changes  will  be  such  as  to  render 
the  repair  of  the  damaged  organ  both  unlikely  to  occur,  and  slow  to  be  ac- 
complished, and  must  leave  it  in  a  condition  peculiarly  liable  to  be  aggra- 
vated during  the  fluctuation  of  circulation,  and  alternations  of  activity 
and  repose,  to  which  the  female  sexual  system  is  liable."  This  is  just  the 
state  to  which  I  allude  at  the  commencement  of  this  chapter,  as  one  exist- 
ing years  after  labor,  and  which,  attended  by  congestion,  displacement, 
catarrh,  and  granular  degeneration,  is  styled  chronic  metritis.  It  is,  I 
think,  this  state  which  most  frequently  furnishes  instances  of  areolar 
hyperplasia  to  the  microscope. 

Let  any  one  faithfully  and  patiently  watch  a  case  of  subinvolution  for  a 
year  or  two  with  reference  to  this  point  as  I  have  repeatedly  done,  and  I 
cannot  doubt  that  he  will  have  the  same  evidence  which  makes  me  so 
strong  in  my  present  belief.  Lastly,  let  it  be  remembered,  that  by  the 
French  school  no  condition  of  arrest  of  development  is  recognized  as  ac- 
counting for  it;  these  are  cases  of  "post-puerperal  metritis,"  metritis, 
according  to  M.  Gallard,2  without  symptoms,  "chronique  d'emblee." 

Does  any  one  claim  that  between  this  condition  and  chronic  metritis  a 
difference  should  be  made?  Let  him  tell  me  by  what  means  he  can  at  the 
bedside  distinguish  one  from  the  other,  and  I  may  agree  with  him.  There 
are  no  means  for  such  differentiation.  If  the  uterus  be  very  large  and 
the  patient  recently  delivered,  the  case  is  termed  subinvolution  by  English 
writers;  if  its  dimensions  have  diminished,  years  have  elapsed  since  par- 
turition, and  the  almost  universal  accompaniments  of  the  condition,  leu- 
corrhoca,  granular  degeneration,  and  displacement,  be  present,  it  is  styled 
chronic  metritis. 

Arrest  of  involution  of  the  puerperal  uterus  is  an  occurrence  of  very 
great  frequency.  It  constitutes  the  chief  cause  of  all  chronic  uterine  dis- 
orders, and  for  this  reason  its  importance  cannot  be  overestimated.  Until 
this  subject  receives  the  attention  which  it  deserves,  the  present  confusion 
as  to  the  causes,  pathology,  and  general  features  of  chronic  metritis,  which 
helps  to  weaken  uterine  pathology,  must  continue. 

As  a  very  general  rule,  areolar  hyperplasia,  the  so-called  chronic  metri- 
tis, is  a  consequence  of  subinvolution.     This  constitutes  the  explanation 

•  Op.  cit.,  p.  89.  *  Op.  cit.,  p.  372. 


PATHOLOGY  OF  AREOLAR  HYPERPLASIA.        317 

of  the  fact  that  so  large  a  number  of  women  with  uterine  affections  refer 
their  illnesses  to  child-bearing,  and  that  so  many  who  are  well  until  that 
process  remain  invalids  afterwards.  Go  back  to  the  commencement  of 
all  cases  of  uterine  disease,  and  a  very  large  proportion  will  date  from 
parturition.  These  hyperplastic  or  subinvoluted  uteri  were  those  which 
chiefly  furnished  Lisfranc's  cases  of  "  engorgement,"  which  Jobert  "  melted 
down"  with  the  actual  cautery,  and  which  hundreds  to-day  are  treating 
by  powerful  caustics  as  parenchymatous  metritis.  The  question  may  be 
asked,  do  1  myself  not  blister,  apply  leeches,  and  even  amputate  the 
cervix  in  these  cases  ?  The  element  which  sustains  the  disease  is  an 
excessive  supply  of  blood  ;  to  diminish  this  is  to  strike  at  the  root  of  the 
evil.  In  areolar  hyperplasia  I  blister  lightly,  to  exert  an  alterative  in- 
fluence upon  the  nerves ;  for  the  relief  of  coincident  congestion,  I  leech 
occasionally,  as  I  would  for  hyperemia  elsewhere  ;  and  I  amputate,  as  I 
would  do  the  enlarged  tonsils ;  but  nowhere  would  I  treat  the  condition  as 
inflammation. 

The  only  apology  which  I  offer  for  enlarging  still  further  upon  this  part 
of  my  subject,  is  contained  in  the  fact  that  I  regard  it  as  one  of  the  most 
important  points  in  the  whole  of  uterine  pathology.  Even  by  Parisian 
writers,  who  above  all  others  have  been  wedded  to  the  theory  of  chronic 
inflammation,  the  dependence  of  a  peculiar  form  of  so-called  chronic  me- 
tritis upon  disordered  involution  has  been  recognized.  "  The  commence- 
ment of  chronic  metritis,"  says  Gallard,1  "is  so  insidious,  that  it  is  often 
difficult  to  determine  its  date  in  each  particular  case.  So  rare  are  cases 
of  true  acute  metritis  which,  in  perpetuating  themselves,  become  chronic, 
that  it  is  generally  admitted  that  the  disease  is,  to  a  certain  extent,  chronic 
from  its  commencement.  Nevertheless,  I  consider  this  passing  of  acute 
into  chronic  metritis  as  much  more  frequent  than  most  authors  think  .  .  . 
Aran,  after  having  contested  this,  was  forced  to  recognize,  as  the  origin 
of  the  greatest  number  of  cases  of  chronic  metritis,  acute  metritis  follow- 
ing parturition.  This  acute  stage  often  passes  unnoticed  among  the  sequeke 
of  labor,  scarcely  disturbed  by  slight  febrile  movements,  which  excite 
no  suspicion  of  uterine  inflammation  so  long  as  they  do  not  present  them- 
selves with  the  alarming  symptoms  so  characteristic  of  puerperal  metritis. 
Here  we  see  arise  a  condition'which  Chomel  with  his  eminently  judicious 
and  practical  mind  was  obliged  to  distinguish  from  this  serious  disease  by 
giving  it  a  particular  name,  that  of  post-puerperal  metritis."  .... 
"  This  inflammation,  which  surprises  the  uterus  before  it  has  finished  the 
work  of  involution  which  would  reduce  it  to  its  normal  size,  finds  in  the 
histological  features  of  this  organ  circumstances  most  favorable  as  well  for 
its  development  as  its  perpetuation  and  its  passage  into  the  chronic  stage." 

If  this  passage  be  read  with  the  key  which  I  here  offer,  it  becomes 

1  Lemons  Cliniques  sur  les  Mai.  des  Femnies,  p.  372. 


318  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

plain  how  a  condition  arises  insidiously  after  labor  without  the  symptoms 
of  inflammation,  and  yet  ends  in  what  is  generally  called  chronic  metritis  ; 
how  a  state  due  to  parturition  differs  so  widely  from  ordinary  puerperal 
metritis,  that  a  new  distinctive  appellation  is  required  for  it ;  how  metritis 
appears  to  commence  in  chronic  form ;  how  Aran  found  this  latent,  un- 
demonstrative, acute  disorder  the  "  source  of  the  majority  of  cases  of 
chronic  metritis;"  and  how,  in  spite  of  the  obscurity  of  early  symptoms, 
M.  Gallard  is  forced  to  believe  that  the  chronic  disease  does  follow  an 
acute  puerperal  metritis,  the  development  of  which  is  obscured  by  the 
sequelai  of  labor.  The  supposed  acute  metritis,  without  symptoms  to 
announce  it,  which  is  conjured  up  to  sustain  an  untenable  theory,  was 
really  an  arrest  of  retrograde  metamorphosis  ;  the  chronic  metritis,  which 
was  afterwards  found  to  exist  in  full  development,  with  a  commencement 
so  obscure  that  it  must  have  been  "chronique  d'emblee,"1  was  this  same 
condition  passing  or  having  passed  into  areolar  hyperplasia.  At  this  time 
its  slowly  retrograding  muscular  fibres  have,  to  a  great  extent,  passed 
away,  but  its  connective  tissue  continues  exuberant,  and  the  uterus  re- 
mains large,  swollen,  tender,  and  heavy. 

Compared  with  interference  with  involution,  all  other  pathological  influ- 
ences become  comparatively  insignificant  as  causes  of  this  condition ; 
nevertheless  they  must  receive  due  weight.  The  tissue  of  the  virgin 
uterus  presents  a  structure  unfavorable  to  this  disorder.  That  of  a  uterus 
once  affected  by  gestation  offers  a  more  propitious  field  for  its  development. 

Displacement  of  the  uterus  at  first  results  in  passive  congestion,  this 
being  kept  up,  hypergenesis  of  connective  tissue  takes  place.  Fibroids, 
whether  they  be  submucous,  subserous,  or  mural,  keep  up  a  constant 
nervous  irritation  that  induces  hyperemia,  which  proves  the  first  step 
towards  this  affection.  In  a  very  important  essay,  Rouget*  proves  the 
uterus  to  be  an  erectile  organ,  as  richly  supplied  with  a  network  of  vessels 
as  such  organs  always  are,  and  very  subject  to  active  physiological  con* 
gestion.  It  is  certain  that  such  a  kind  of  hyperemia  attends  ovulation, 
and  it  is  highly  probable  that  sexual  congress  has  a  similar  result.  From 
this  it  will  appear  how  prolongation  of  the  molimen  menstmationis,  and 
excessive  indulgence  in  sexual  intercourse,  especially  near  menstrual 
epochs,  may  produce  evil  consequences.3 

As  cardiac  diseases  and  abdominal  tumors,  which  interfere  with  venous 
return  through  the  vena  cava,  produce  blood  stasis  and  oedema  of  the  feet, 
of  the  labia  majora,  and  of  the  parts  about  the  vagina,  so  do  they  result  in 
the  same  way  in  the  uterus.     Klob  declares  that  this  purely  passive  con- 

'  Gallard,  op.  cit. 

2  Rouget — Recherches  sur  les  Organes  6rectiles  de  la  Femme. 

3  Scanzoni  calls  attention  to  the  fact  that  it  is  met  with  in  prostitutes. 


PATHOLOGY    OF    AREOLAR    HYPERPLASIA.  319 

gestion  is  capable  of  inducing  hypernutrition  and  hypertrophy  of  the  con- 
nective tissue.1 

It  has  been  already  said  that  in  acute  endometritis  the  hyperemia 
attending  the  disease  ordinarily  extends  to  the  parenchymatous  layers 
immediately  adjacent  to  the  diseased  mucous  membrane,  and  that  in 
chronic  endometritis  there  is  often  in  the  submucous  connective  tissue  an 
absolute  hypertrophy.  In  some  cases  the  process  passes  into  a  diffuse 
proliferation  of  the  connective  tissue  of  the  entire  uterine  wall.  Thus  as 
a  result  of  cervical  endometritis  we  sometimes  find  cervical  hyperplasia 
resulting,  and  so  with  the  disease  in  the  cavity  of  the  body.  As  I  have 
already  stated,  where  the  uterine  parenchyma  has  never  undergone  that 
physiological  hypertrophy  and  retrograde  metamorphosis  attendant  upon 
utero-gestation,  endometritis  will  continue  for  a  long  period  without  ex- 
citing hyperplasia;  but  where  such  changes  have  occurred,  the  more 
loose  and  permeable  texture  offers  itself  as  an  easier  prey  to  the  morbid 
process.  Thus  cervical  endometritis  will  continue  for  years  in  a  virgin 
without  any  apparent  enlargement  of  the  structure  of  the  neck,  while  such 
a  result  soon  follows  in  a  woman  who  has  borne  children.  This  fact  has 
not  attracted  special  attention,  and  yet  it  is  a  point  which  every  practi- 
tioner must  recognize,  when  it  is  brought  to  his  attention,  as  one  which  is 
familiar.  Under  these  circumstances  the  enlargement  is  not  due  to  any- 
thing absolutely  connected  with  parturition.  Parturition  has  been  the 
predisposing  cause;  endometritis  the  exciting. 

A  very  striking  illustration  of  this  affection  due  to  non-puerperal  causes 
is  related  by  Dr.  West,  whose  observation  seems  to  have  led  him  to  very 
similar  conclusions  with  mine.  "Some  years  ago,"  says  he,  "I  saw  a 
lady,  aged  forty-three,  who,  during  thirteen  years  of  married  life,  had 
never  been  pregnant.  She  had  always  menstruated  painfully,  and  rather 
profusely ;  and  both  these  ailments  had  by  degrees  grown  worse,  and  this 
especially  during  the  last  few  months.  She  complained  of  a  sense  of 
weight  and  dragging  immediately  on  making  any  attempt  to  walk,  and 
induced  even  by  remaining  long  in  the  sitting  posture.  .  .  .  Men- 
struation was  very  profuse,  accompanied  by  discharge  of  coagula,  while  at 
uncertain  intervals  during  its  continuance  most  violent  paroxysms  of 
uterine  pain  came  on.  On  examination  the  enlarged  uterus  was  distinctld 
felt  above  the  symphysis  pubis,  as  large  as  the  doubled  fist,  and  per 
vaginam  the  whole  organ  was  found  much  enlarged,  and  much  heavier 
than  natural;  the  cervix  large  and  thick,  but  not  indurated;  the  os  uteri 
small  and  circular;  and  the  hymen  was  entire."  He  goes  on  to  say: 
'"AVhenever  the  uterus  is  exposed  to  unusual  irritation,  it  increases  in 
size ;  not  necessarily,  nor  I  believe  generally,  as  the  result  of  inflamma- 

1  Klob,  op.  cit.,  p.  130. 


320  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

tion,   but   because   tbe  organ   is   composed  of  formative  material,  which 
excitement  of  any  kind  will  call  into  active  development." 

In  the  first  stage  of  the  disease,  the  hypertrophied  areolar  tissue  is  con- 
gested, containing  absolutely  more  blood  than  normal,  and  the  whole  of 
the  affected  part,  neck,  body,  or  entire  uterus,  is  greatly  increased  in  size 
and  weight.  As  time  passes,  the  second  stage  of  the  disorder  supervenes, 
and  an  opposite  state  of  things  is  set  up.  Klob  describes  it  in  these 
words:  "The  parenchyma  on  section  appears  white  or  of  a  whitish-red 
color,  deficient  in  bloodvessels,  from  compression  of  the  capillaries  by  the 
contraction  of  the  newly  formed  connective  tissue,  or  from  partial  destruc- 
tion or  obliteration  of  vessels  during  the  growth  of  tissue;  the  firmness  of 
the  uterine  substance  is  also  increased,  simulating  the  hardness  of  carti- 
lage, and  creaking  under  the  knife."  This  constitutes  a  true  sclerosis1  of 
the  uterus. 

Every  practitioner  must  have  met  with  cases  in  which  a  large,  red, 
engorged,  and  soft  uterus,  examined  after  an  interval  of  several  years, 
has  been  found,  to  his  surprise,  to  have  become  small,  densely  hard,  white, 
and  anaemic,  and  its  cavity  diminished  in  size.  Such  an  organ  removed  • 
from  the  body  cuts  like  fibrous  tissue,  and  appears  when  cut  almost  as 
dense  and  bloodless. 

In  leaving  this  important  and  interesting  part  of  my  subject,  let  me  sum 
up  what  has  been  said,  in  a  few  words  : — 

1st.  The  condition  ordinarily  styled  chronic  metritis  consists  in  an  en- 
largement due  to  hypergenesis  of  its  tissues,  especially  of  its  connective 
tissue,  which  induces  nervous  irritability,  and  is  accompanied  by  con- 
gestion. 

2d.  Decidedly  the  most  frequent  source  of  this  state  is  interference  with 
involution  of  the  puerperal  uterus.  A  very  large  proportion  of  the  cases 
of  so-called  chronic  parenchymatous  metritis  are  really  later  stages  of 
subinvolution. 

3d.  Areolar  hyperplasia  is  often  induced  in  a  uterus  which  has  once 
undergone  the  development  of  pregnancy,  by  displacement,  endometritis, 
and  other  conditions  inducing  persistent  hypersemia. 

4th.  The  same  influences  may  possibly  produce  it  in  the  nulliparous 
uterus,  most  frequently  they  do  so  in  the  neck,  but  such  a  result  is  ex- 
ceedingly infrequent. 

5th.  However  produced,  the  condition  is  one  of  vice  of  nutrition  engen- 
dering hyperplasia  of  connective  tissue  as  its  most  striking  feature,  and, 
although  attended  by  many  of  the  signs  and  symptoms  of  inflammation,  it 
in  no  way  partakes  of  the  character  of  that  process. 

It  has  been  maintained  by  some  that  acute  puerperal  metritis  extends 

1  The  term  sclerosis  was,  I  believe,  first  applied  to  this  condition  by  Skene,  of 
Brooklyn.     Subsequently  Gallard  likewise  employed  it. 


COURSE    AND    TERMINATION, 


321 


itself  into  the  chronic  metritis  of  the  non-puerperal  state,  and  this  form  of 
the  affection  has  been  differentiated  from  subinvolution.  I  have  seen  no 
evidence  of  the  correctness  of  this  view,  nor  do  I  believe  that  any  such 
distinction  can  be  made  at  the  bedside. 

Course  and  Termination. — The  length  of  time  which  this  condition  may 
last  is  very  uncertain.  After  the  connective  tissue  once  becomes  thor- 
oughly affected  by  the  disease,  it  rarely  returns  to  its  original  condition, 
but  so  complete  is  the  relief  which  may  be  afforded  the  patient  by  removal 
of  those  concomitant  conditions  that  attend  upon  it  and  increase  the  dis- 
comforts which  are  due  to  it,  that  she  will  often  for  years  imagine  herself 
well.  Very  suddenly,  however,  imprudence  during  menstruation,  the  act 
of  parturition,  over-exertion,  or  some  other  influence  creating  congestion, 
will  produce  a  relapse  which  will  convince  her  of  her  error.  It  is  aston- 
ishing to  what  an  extent  enlargement  of  the  cervix  as  a  result  of  areolar 
hyperplasia  will  go.  Sometimes  this  part  will  equal  in  size  a  very  small 
orange,  and,  filling  the  vagina,  will  compress  the  rectum  to  such  an  extent 
as  to  interfere  with  its  functions.  Uninterfered  with  by  art  the  disease 
has  no  fixed  limits.  The  increase  of  uterine  weight  which  it  induees 
usually  results  in  displacement.  This  increases  already  existing  conges- 
tion, and  the  patient  suffers,  until  the  menopause  at  least,  from  endome- 
tritis, granular  cervix,  and  the  ordinary-symptoms  of  displacement. 


Fig.  122. 


Fro.  123. 


The  dots  represent  the  site  of  cervica 
hyperplasia. 


The  dots  represent  the  site  of  corporeal 
hyperplasia. 


In  some  cases  contraction  of  the  exuberant  tissue  occurs,  and  uterine 
atrophy  with  its  accompanying  symptoms  takes  place. 

Varieties — Whatever  be  its  cause,  areolar  hyperplasia  may  affect  the 
21 


322  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

entire  uterus  ;  it  may  limit  itself  to  the  neck,  extending  from  the  os  exter- 
num to  the  os  internum ;  or  it  may  affect  the  body  from  the  os  internum 
to  the  fundus.  The  habitat  of  hyperplasia  limited  to  the  cervix  is  repre- 
sented by  Fig.  122,  while  Fig.  123  represents  that  of  the  corporeal  variety. 

"Whether  arising  from  imperfect  involution  or  from  non-puerperal  causes, 
this  limitation  to  cervix  or  body  will  be  frequently  observed.  Dr.  West1 
alludes  to  the  cervical  variety  as  "  one  in  which  the  enlargement  is  limited 
to  the  neck  of  the  womb,  and  sometimes  even  involves  only  one  lip,  gene- 
rally the  anterior.  In  the  latter  case  it  is  usually  consequent  on  child- 
bearing,  and  perhaps  is,  strictly  speaking,  rather  the  result  of  a  partial 
deficiency  of  involution  of  the  uterus  than  the  effect  of  a  generic  hyper- 
trophy of  the  part."  This  fact  was  first  announced  in  Great  Britain  by 
Dr.  Evory  Kennedy. 

Frequency This  affection  is  one  of  great  frequency,  and  as  it  was 

formerly  universally  regarded  as  chronic  parenchymatous  metritis,  this  is 
one  great  reason  why  inflammation  of  the  structure  of  the  uterus  was 
thought  to  be  so  common.  This  fact  makes  its  careful  study  a  matter  of 
great  moment  to  the  gynecologist.  I  do  not  hesitate  to  declare  that,  he 
who  fully  masters  it  and  thoroughly  appreciates  its  frequency  and  influ- 
ence will  possess  a  key  to  the  management  of  numerous  cases  which  would 
in  vain  be  sought  for  elsewhere. 

As  I  have  before  remarked,  interference  with  that  retrograde  metamor- 
phosis of  the  puerperal  uterus  which  is  now  styled  involution  is  in  the 
great  majority  of  cases  its  cause.  Surprise  may  for  this  reason  be  excited 
by  the  assertion  that  of  all  forms  of  the  affection,  the  cervical  variety  is 
the  most  frequent.  The  reason  for  this  is  to  be  found  in  the  facts  that  cer- 
vical endometritis,  which  in  multiparous  women  proves  a  not  infrequent 
source  of  the  disorder,  is  more  common  than  the  kindred  affection  of  the 
body  ;  that  the  cervix  is  peculiarly  exposed  to  mechanical  injury  from 
coition,  friction  against  the  vaginal  walls,  and  laceration,  occurring  during 
parturient  distention  ;  that  after  childbearing  the  connective  tissue  at  this 
point  is  looser  and  more  permeable  than  that  of  the  body ;  and  that  when 
involution  is  retarded  for  some  months  and  then  is  accomplished,  it  some- 
times takes  place  in  the  body,  but  fails  to  do  so  in  the  neck  from  that  expo- 
sure to  injurious  influences  which  has  just  been  alluded  to. 

The  body  of  the  uterus  is  so  completely  removed  from  contact  with 
mechanical  agencies  outside  of  the  abdomen  that  this  part  of  the  organ,  as 
already  stated,  is  not  so  frequently  affected  by  hyperplasia  as  the  corre- 
sponding tissue  of  the  cervix.  Still  it  is  by  no  means  unfrequently  diseased. 
A  large  number  of  cases  of  obstinate  uterine  disorders  occurring  as  a  re- 
mote result  of  parturition  are  really  of  this  nature,  and  the  displacements, 
rebellious  leucorrhoea,  and  other  concomitant  evils  which  characterize  them, 

•  Op.  cit.,  p.  93. 


PREDISPOSING    CAUSES.  323 

are  merely  symptoms  of  this  affection  or  of  some  of  its  resulting  complica- 
tions. An  important  fact  connected  with  this  state  is  that  where  hyper- 
trophy of  the  connective  tissue  exists,  transient  attacks  of  active  congestion 
frequently  occur  and  excite  acute  symptoms.  These  pass  away,  leaving 
the  hasis  of  the  affection  in  its  original  state,  again  to  return  with  all  the 
signs  of  relapse.  And  thus  a  series  of  short  but  severe  exacerbations  go 
on  developing  themselves  in  the  ordinary  course  of  an  attack  of  the  dis- 
order. 

Predisposing  Causes These  may  be  enumerated  as — 

A  depreciation  of  the  vital  forces  from  any  cause  ; 

Constitutional  tendency  to  tubercle,  scrofula,  or  spanremia ; 

Parturition,  especially  when  repeated  often  and  with  short  intervals  ; 

Prolonged  nervous  depression  ; 

A  torpid  condition  of  the  intestines  and  liver. 
Nulliparity  secures,  to  a  very  great  extent,  an  immunity  from  the  dis- 
ease, and  multiparity  constitutes  a  most  important  predisposing  cause. 
This  fact  arises  not  merely  from  its  being,  as  it  often  is,  an  immediate 
consequence  of  the  parturient  act,  but  from  the  peculiar  tissue  changes  of 
utero-gestation  rendering  the  uterus  prone  to  its  development.  "  Fre- 
quently," says  Klob,  "  this  proliferation  of  connective  tissue  is  developed 
after  repeated  deliveries  in  rapid  succession  without  any  previous  or  exist- 
inf  inflammation,  ....  and  sometimes  is  developed  in  consequence 
of  the  puerperal  condition."  Its  "  causes  must  be  sought  for  in  habitual 
hyperaemia;"  consequently  whatever  state  gives  a  tendency  to  this  must  be 
regarded  as  a  predisposing  cause,  while  one  which  induces  and  perpetuates 
it  must  be  looked  upon  as  exciting.  The  woman  who  has  never  been 
pregnant  is  much  less  liable  to  areolar  hyperplasia  than  she  whose  uterus 
has  undergone  the  tissue  changes  of  utero-gestation.  Nevertheless,  in  very 
rare  and  exceptional  cases,  I  think  that  she  may  suffer  from  it.  In  the 
.  whole  of  my  experience  I  have  seen  but  two  or  three  cases,  and  the 
diagnosis  in  these  is  based  upon  clinical  evidence  alone. 

Here  let  me  guard  the  reader  against  a  fallacious  argument  which  is 
often  used  in  reference  to  this  matter.  As  areolar  hyperplasia  is  rarely 
seen  except  in  women  who  have  borne  children,  it  is  said  that  it  is  always 
the  result  of  interference  with  involution.  This  is  incorrect.  A  woman 
bears  a  child,  has  no  post-partum  trouble,  and  goes  through  uterine  invo- 
lution perfectly.  A  year  or  two  afterwards  she  has  endometritis.  This 
in  time  produces  areolar  hyperplasia  with  its  usual  symptoms  and  physical 
signs.  The  same  kind  and  degree  of  endometritis  in  a  nulliparous  woman 
would  have  lasted  for  years  without  parenchymatous  complication.  In 
the  former  case  the  endometric  disease  existed  on  ground  favorable  to 
hyperplasia,  because  an  important  predisposing  cause  existed.  In  the 
latter  such  predisposition  was  wanting. 


324         AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

The  exciting  causes  are  the  following  : — 

Over-exertion  after  delivery  ; 

Puerperal  pelvic  inflammation  ; 

Laceration  of  the  cervix  uteri ; 

Displacements ; 

Endometritis ; 

Neoplasms ; 

Cardiac  disease  ; 

Abdominal  tumors  pressing  on  the  vena  cava ; 

Excessive  sexual  intercourse. 
After  delivery  many  of  both  these  sets  of  causes  are  developed  by  the 
pernicious  system  of  management  which  nurses  frequently  adopt.  The 
nerve  and  blood  states  of  the  woman  are  depreciated  by  starvation,  impure 
air,  and  disturbance  of  sleep  by  attention  to  the  wants  of  a  child,  while 
the  enlarged  uterus  is  forced  into  retroversion  and  the  congestion  which  it 
induces,  by  a  very  tight  bandage,  rendered  still  more  hurtful  by  a  thick 
compress  over  the  uterus.  The  practitioner  who  regards  delivery  of  the 
placenta  as  the  end  of  the  third  stage  of  labor  furnishes  a  marked  predispos- 
ing cause.  The  third  stage  of  labor  consists  in  complete  and  permanent 
contraction  of  the  uterus,  and  may  not  be  accomplished  for  hours  after  the 
expulsion  of  the  placenta.  No  obstetrician  has  done  his  duty  who  leaves 
his  patient  before  its  accomplishment. 

Symptoms It  is  impossible  to  present  the  symptoms  of  this  condition 

entirely  separated  from  those  of  complications  which  very  commonly  at- 
tend it,  such,  for  example,  as  displacement,  laceration  of  the  cervix, 
ovarian  congestion,  granular  cervix,  etc.  These  states  of  course  produce 
svmptoms  of  their  own  which  mingle  with  those  of  the  main  disorder. 
The  symptoms  then,  which  are  due  to  areolar  hyperplasia  and  its  almost 
inevitable  complications,  are  the  following.  If  the  cervix  alone  be  affected 
there  are — 

Pain  in  back  and  loins ; 

Pressure  on  bladder  or  rectum  ; 

Disordered  menstruation ; 

Difficulty  of  locomotion  ; 

Nervous  disorder ; 

Pain  on  sexual  intercourse  ; 

Dyspepsia,  headache,  and  languor  ; 

Leucorrhoea. 
If  the  affection  be  general  or  corporeal,  graver  symptoms  manifest  them- 
selves.1     Chief  among  these  are — 

1  It  must  not  be  supposed  that  all  these  symptoms  occur  in  all  or  even  in  the 
majority  of  cases.  In  many  cases  few,  and  in  some  almost  none  of  them  will  be 
recognized. 


PHYSICAL    SIGNS.  325 

A  dull,  heavy,  dragging  pain  through  the  pelvis,  much  increased  1>y 
locomotion  ; 

Tain  on  defecation  and  coition  ; 

Dull  pain  beginning  several  days  before  menstruation,  and  lasting  dur- 
ing that  process ; 

Pain  in  the  mamma?,  before  and  during  menstruation  ; 

Darkening  of  the  areola;  of  the  breasts  ; 

Nausea  and  vomiting ; 

Great  nervous  disturbance ; 

Pressure  on  the  rectum  with  tenesmus  and  hemorrhoids  ; 

Pressure  on  the  bladder  with  vesical  tenesmus ; 

Sterility. 

Physical  Signs  of  Cervical  Hyperplasia Vaginal  touch  will  gene- 
rally discover  that  the  uterus  has  descended  in  the  pelvis  so  that  the  cer- 
vix will  rest  upon  its  floor.  The  cervix  will  be  found  to  be  large,  swollen, 
and  painful,  and  the  os  may  admit  the  tip  of  the  finger.  If  the  finger  be 
placed  under  the  cervix  and  it  be  lifted  up,  pain  will  usually  be  complained 
of,  and  if  it  be  introduced  into  the  rectum  so  as  to  press  upon  the  cervix 
as  high  as  the  os  internum,  it  will  often  reveal  a  great  degree  of  sensitive- 
ness. Under  these  circumstances  the  direction  of  the  uterine  axis  will 
generally  be  found  to  be  abnormal.  The  cervix  will  in  some  cases  have 
moved  forwards  and  the  body  backwards,  or  the  opposite  change  of  place 
may  have  occurred. 

Physical  Signs  of  Corporeal  Hyperplasia If  two  fingers  be  carried 

into  the  vagina  and  placed  in  front  of  the  cervix  so  as  to  lift  the  bladder 
and  press  against  the  uterus,  while  the  tips  of  the  fingers  of  the  other 
hand  be  made  to  depress  the  abdominal  walls,  the  body  of  the  uterus  will, 
unless  the  woman  be  very  fat,  be  distinctly  felt,  should  the  organ  be  ante- 
flexed.  Should  it  not  be  detected,  let  the  two  fingers  in  the  vagina  be 
now  carried  behind  the  cervix  into  the  fornix  vaginas,  and  the  effort  re- 
peated ;  if  the  uterus  be  retroflexed  or  retroverted,  or  even  in  its  normal 
place,  it  will  be  detected  at  once.  By  these  means  we  may  not  only  learn 
the  size  and  shape  of  the  organ,  but  its  degree  of  sensitiveness.  This  may 
likewise  be  accomplished  to  a  certain  extent  by  rectal  touch.  The  ute- 
rine probe  may  then  be  introduced,  the  cavity  measured,  and  the  sensi- 
tiveness of  the  walls  carefully  ascertained. 

A  point  which  should  be  settled  before  the  diagnosis  can  be  considered 
complete  will  be,  whether  the  cervix  alone  is  affected,  or  whether  its  en- 
largement is  only  a  part  of  a  general  uterine  development.  To  determine 
this  question,  two  means  are  at  command:  first,  the  examiner,  introducing 
one  or  two  fingers  under  the  body  of  the  uterus,  and  depressing  the  abdo- 
minal walls  by  the  other  hand,  so  as  to  clasp  the  fundus,  ascertains  whether 
it  is  larger  than  it  should  be,  or  of  normal  size  and  free  from  sensitiveness. 


326  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

He  then  passes  the  uterine  probe  into  the  cavity  of  the  body,  and  meas- 
ures it.  If  the  uterine  cavity  be  increased  in  size,  the  evidence  is  in 
favor  of  the  disease  having  extended  to  the  tissue  of  the  body.  Should 
its  size  be  normal,  this  is  probably  not  the  case.  This  sign  is  not,  how- 
ever, to  be  entirely  relied  upon. 

Differentiation When  the  whole  uterus  is  affected,  or  the  body  of  the 

organ  alone  is  enlarged,  the  diseases  with  which  areolar  hyperplasia  may 
be  confounded  in  its  first  stage,  are  : — 
Pregnancy  ; 
Neoplasms ; 
Periuterine  inflammations. 

From  these  a  careful  differentiation  should  be  made;  for  if  in  error,  the 
practitioner  would  not  only  fail  in  giving  relief,  but,  in  some  cases,  might 
do  great  injury.  For  example,  an  examination  by  the  probe  might  pro- 
duce abortion,  or  so  aggravate  periuterine  inflammation,  as  to  cause  seri- 
ous and  alarming  consequences.  The  introduction  of  the  probe  or  sound 
should,  for  this  reason,  be  practised  with  great  caution,  and  only  when 
pood  reason  exists  for  supposing  pregnancy  and  periuterine  inflammation 
absent. 

Between  pregnancy  and  endometritis  with  corporeal  hyperplasia,  there 
is  a  chance  of  error  in  diagnosis ;  for  in  both  there  are  enlargement  of  the 
breasts,  darkening  of  the  areola;,  enlargement  of  the  uterus,  derangement 
of  the  nervous  system,  and  nausea  and  vomiting.  In  the  one,  however, 
menstruation  does  not  cease,  there  is  no  kiesteine  in  the  urine,  there  is 
great  sensitiveness  of  the  body  of  the  uterus,  and  an  abundant  leucorrhoea. 
Dr.  Tilt  has  drawn  especial  attention  to  this  important  fact,  in  connection 
with  endometritis :  "  When  most  of  the  symptoms  of  early  pregnancy  are 
present,"  says  he,  "  without  menstruation  being  suspended,  in  compara- 
tively young  women,  internal  metritis  may  be  suspected." 

Fibrous  growths  in  the  uterine  walls  will  sometimes,  from  the  peculiar 
symmetry  of  their  development,  completely  mislead  us,  giving  uterine 
enlargement,  leucorrhoea  of  bloody  character,  etc.  I  have  now  in  my 
possession  a  uterus  in  the  anterior  wall  of  which  a  fibrous  tumor,  equal  in 
size  to  a  goose's  egg,  gives  upon  superficial  examination  all  the  appear- 
ances of  engorgement  and  hypertrophy  of  uterine  tissue  with  anteflexion 
and  endometritis.  In  the  same  manner  polypoid  growths  or  submucous 
fibroids  might  give  trouble  in  diagnosis.  Under  such  circumstances 
reliance  would  have  to  be  placed  upon  the  use  of  the  sound,  conjoined 
manipulation,  and  tents,  together  with  the  rational  signs. 

Periuterine  inflammations  fix  the- uterus,  create  hardness  and  swellings 
in  the  iliac  fossae  and  pouch  of  Douglas,  and  sometimes  produce  purulent 
discharges. 

Sometimes,  suspicion  of  scirrhous  cancer  in  an  early  period  being  enter- 
tained, it  becomes  necessary  to  decide  between  its  existence  and  that  of 


PROGNOSIS — COMPLICATIONS.  327 

the  second  stage  of  areolar  hyperplasia  or  sclerosis.  Scanzoni  doubts  the 
possibility  of  deciding,  but  it  appears  to  me  that  the  investigator  will 
usually  succeed  in  doing  so,  by  the  following  comparison  of  signs  and 
symptoms  : — 

In  Cervical  Sclerosis.  In  Scirrhous  Cancel-. 

The  patient  shows  no  cachexia.  She  often  does. 

There  is  tendency  to  amenorrhcea.  There  is  tendency  to  hemorrhage. 

The  history  usually  points  to  parturition.  It  does  not. 
It  has  been  preceded  by  symptoms  of  uterine     It  has  not. 

enlargement. 

The  cervix  feels  like  dense  fibrous  tissue.  It  feels  almost  like  cartilage. 

The  body  is  perhaps  implicated.  It  is  very  rarely  so. 

A  sponge-tent  softens  the  tissue.1  It  leaves  it  hard  and  dense. 

Prognosis The  prognosis  in  hyperplasia  of  the  entire  uterus  or  of  the 

body  alone  is  unfavorable  with  regard  to  complete  cure,  though  highly 
favorable  with  reference  to  great  relief  of  symptoms  and  to  danger  to  life. 
Should  the  patient  be  approaching  the  menopause,  it  is  possible  that,  after 
the  functions  of  the  uterus  cease,  atrophy  may  occur  and  relief  be  ob- 
tained. But  one  cannot  be  sure  even  of  this,  for  the  monthly  discharge 
may  give  place  to  metrorrhagia,  or  all  the  symptoms  may  continue  in 
spite  of  the  menstrual  cessation.  Under  a  course  of  local  treatment,  com- 
bined with  one  conducted  with  special  reference  to  the  general  system, 
hope  may  always  be  held  out  that,  although  restoration  of  the  uterus  to 
its  normal  condition  may  not  be  effected,  the  evils  resulting  from  the 
complications  of  this  disease  can  be  so  fully  controlled  that  comfort  will 
be  obtained.  When  the  neck  of  the  uterus  alone  is  affected,  a  favorable 
prognosis  may  always  be  made,  for  here  there  are  fewer  grave  complica- 
tions to  be  encountered ;  such,  for  example,  as  corporeal  endometritis, 
menorrhagia,  etc.  The  diseased  part  is  likewise  more  accessible  to  local 
treatment,  and  is  also  a  much  less  sensitive  and  important  part  of  the 
organism  ;  I  might  indeed  almost  say  a  less  important  organ,  so  distinct 
are  the  uterine  body  and  neck  physiologically  and  pathologically.  As  I 
have  elsewhere  stated,  the  prognosis  will  depend  in  a  great  degree  upon 
the  patient.  If  she  be  unwilling  to  sacrifice  her  inclinations  and  pleasures, 
but  half  fulfd  the  directions  of  the  attending  physician,  and  clandestinely 
expose  herself  to  prejudicial  influences,  the  treatment  will  accomplish 
nothing.  In  the  case  of  a  reasonable  patient,  who  appreciates  what  is  at 
stake,  and  is  anxious  to  regain  her  health,  it  may  be  regarded  as  favorable. 

Complications — Areolar  hyperplasia  may  give  rise  to  many  and  serious 
complications,  as,  for  example,  displacements,  cystitis,  rectitis,  cellulitis, 
endometritis,  menstrual  disorders,  hysteria,  dyspepsia,  ovarian  disorders, 
etc. 

1  This  test  origiuated  with  Spiegelberg. 


328       AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

The  question  has  been  raised  by  Dr.  Noeggerath  as  to  the  causative 
influence  of  this  disease  in  the  production  of  cancroid  affections.  In  an 
essay  read  before  the  New  York  Academy  of  Medicine  in  1869,  he 
reported  six  cases  which  he  regarded  as  due  to  the  "  transformation  of  the 
tissue  affected  with  chronic  metritis  into  epithelioma  or  cauliflower  ex- 
crescence." The  object  of  the  essay  was  "  to  prove  that  the  tissue  of  the 
uterus  affected  with  chronic  metritis  is  apt  to  be  transformed  into  papillary 
epithelioma."  My  experience  has  never  furnished  me  with  a  case  illus- 
trative of  the  correctness  of  Dr.  Noeggerath's  opinion.  It  certainly  can- 
not be  an  ordinary  sequence  of  events,  for  the  subject  long  ago  attracted 
attention,  and  I  know  of  no  recent  author  who  takes  similar  ground. 
Klob's1  opinion  is  expressed  in  these  words:  "What  has  been  said  by 
various  authors  on  the  relations  of  diffuse  growth  of  connective  tissue  to 
the  development  of  carcinoma  must  be  considered  as  a  mere  hypothesis." 

Treatment. — Let  me  urge  upon  the  practitioner,  as  a  rule  to  be  observed 
in  every  case,  before  treatment  is  adopted  for  this  disorder,  to  examine 
for  and  remove,  if  discovered,  the  five  following  complications  which  very 
often  accompany  areolar  hyperplasia,  and  establish  symptoms  which 
greatly  increase  the  evils  attending  it.  So  important  do  I  consider  them, 
that  I  give  them  decided  prominence. 

1st.  Laceration  of  the  cervix  uteri,  which  creates  intense  nervous  irri- 
tation, both  immediate  and  reflex,  and  consequent  uterine  congestion  and 
neuralgia. 

2d.  Displacement  of  the  uterus,  which  results  in  vascular  engorgement, 
dragging  upon  uterine  ligaments,  mechanical  interference  with  surround- 
ing parts,  and  difficulty  in  locomotion. 

3d.  Fungoid  degeneration  of  the  endometrium,  which  results  in  profuse 
leucorrhoeal  and  bloody  discharges. 

4th.  Granular  and  cystic  degeneration  of  the  cervix,  which  produce 
nervous  and  vascular  derangement  of  the  uterus,  leucorrhcea,  and  menor- 
rhagia. 

5th.  Vaginitis,  which  is  excited  by  the  discharge  dependent  upon  en- 
gorgement of  the  endometrium. 

He  will  be  most  successful  in  the  treatment  of  areolar  hyperplasia  who 
most  assiduously  searches  for  and  cures  these  complicating  conditions  be- 
fore addressing  remedies  to  the  main  affection. 

Laceration  of  the  cervix,  and  exposure  of  the  delicate  walls  of  the  cer- 
vical canal  to  friction  against  the  vagina,  is  so  frequently  not  only  a  con- 
comitant circumstance  but,  I  think,  a  cause  of  this  condition,  by  interfering 
with  involution,  that  it  should  always  be  looked  for.  Let  it  not  be  sup- 
posed that  a  mere  visual  inspection  will  reveal  its  existence.     It  will  often 

1  It  must  be  noted  that  Klob  alludes  to  carcinoma,  while  Noeggerath  limits  his 
statement  to  epithelioma. 


TREATMENT.  329 

fail  to  do  so  while  the  red  and  excoriated  cervical  walls  are  being  for  long 
periods  treated  for  so-called  ulceration  by  caustics  and  alteratives.  To  test 
the  question,  a  tenaculum  should  be  fixed  in  each  labium  cervicis,  and 
these  should  be  approximated  so  as  to  present  to  the  eyes  of  the  examiner 
the  perfect  cervix  as  it  existed  before  the  accident.  Once  discovered,  the 
inner  surfaces  of  the  torn  lips  should  be  thoroughly  pared  and  brought  to- 
gether by  suture.  Such  an  operation  will  often  have  a  most  happy  effect 
upon  the  uterine  disorder ;  nervous  irritability  will  disappear,  and  nutri- 
tion become  greatly  improved  by  removal  of  this  focus  of  irritation. 

If  displacement  exist,  great  benefit  will  be  obtained  from  support  ren- 
dered by  means  of  a  light  and  well-fitting  pessary,  the  elastic  ring  of  Meigs 
if  there  be  merely  direct  descent ;  Hodge's  double  lever  or  one  of  its  varie- 
ties if  there  be  retroversion  ;  or  an  anteversion  pessary  if  the  uterus  have 
fallen  forwards.  In  some  cases  the  benefit  derived  from  these  instruments 
will  be  the  chief,  perhaps  the  only  relief  which  we  can  bestow,  and  even 
where  we  cannot  cure  the  disease  we  may  by  their  use  render  life  much 
more  agreeable  by  the  alleviation  of  discomfort. 

If  evidences  of  fungoid  growths  on  the  endometrium  exist,  the  whole 
cavity  should  be  gently  scraped  by  the  wire-loop  curette,  and  this  source 
of  leucorrhoea,  metrorrhagia,  and  uterine  congestion  taken  away. 

At  the  same  time  that  I  have  elsewhere  urged  that  too  great  importance 
should  not  be  given  to  granular  and  cystic  degeneration  of  the  cervix,  I 
would  not  ignore  the  fact  that,  once  established,  they  become  a  source  of 
irritation,  and  thus  of  uterine  engorgement.  They  should  by  all  means  be 
treated  and  removed. 

Vaginitis  is  secondary  to  uterine  catarrh,  which  is  a  very  common  ac- 
companiment of  hyperplasia.  It  should  be  treated  by  the  ordinary  means 
elsewhere  indicated,  and  a  recurrence  prevented  by  relief  of  the  endome- 
trial disease. 

The  subject  carefully  analyzed  presents  itself  in  this  way.  If  the  ab- 
normal condition,  which  has  created  areolar  hyperplasia,  has  passed  away, 
this  condition  is  not  in  itself  the  source  of  many  disagreeable  symptoms. 
No  woman  thus  affected  feels  perfectly  well,  but  she  is  often  sufficiently 
comfortable  to  be  able  to  perform  all  her  duties  in  life.  But  the  uterus 
thus  diseased  is  peculiarly  liable  to  certain  complicating  conditions  which 
have  just  been  mentioned,  and  these  create  a  great  deal  of  discomfort  by 
production  of  pains  in  the  back  and  loins,  nervousness,  leucorrhoea,  and 
menstrual  disorders.  These  symptoms  are  then  in  a  great  degree,  as  I 
stated  in  giving  the  symptomatology  of  hyperplasia,  due  to  the  complica- 
tions of  the  disorder,  and  not  to  the  disorder  itself.  In  other  words,  sus- 
tain a  hyperplastic  uterus,  keep  it  free  from  displacement,  granular  and 
cystic  disease  of  the  cervix,  and  uterine  catarrh,  and  the  patient  will  be  so 
comfortable  as,  in  most  instances,  to  feel  satisfied  with  her  condition. 
Sometimes  this  is  all  that  we  can  accomplish.     The  mere  fact  of  accom- 


330  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

plishing  these  results  will,  however,  do  much  for  the  cure  of  the  disease 
itself.  Relief  of  displacement  favors  free  venous  return  and  prevents  con- 
gestion which  feeds  and  perpetuates  hyperplasia.  Cure  of  uterine  catarrh 
and  of  granular  and  cystic  degeneration  of  the  cervix  removes  two  "Teat 
causes  for  hyperemia  of  mucous  and  submucous  tissues.  The  means  em- 
ployed for  the  relief  of  these  symptoms  even  do  more,  they  tend  by  their 
own  direct  influence  to  alter  the  morbid  state  of  the  nerves  of  the  part,  to 
diminish  the  calibre  of  bloodvessels  under  their  control,  and  thus  to  check 
excessive  nutrition  and  secretion. 

All  complications  being  removed,  the  practitioner  has  now  to  deal  with 
a  large,  heavy  uterus,  the  tissue  of  which  is  exuberant,  the  bloodvessels 
enlarged,  and  the  nerves  in  a  condition  of  hyperesthesia. 

Let  me  enumerate  the  indications  to  be  met  by  a  few  leading  proposi- 
tions. 

1st.  Everything  possible  should  be  done  to  prevent  congestion,  and 
remove  that  already  existing. 

2d.  Every  attention  should  be  given  to  the  restoration  of  the  general 
system,  especially  the  blood  and  nerve  states. 

3d.  All  weight  should  be  taken  from  the  large  and  heavy  uterus. 
4th.  Nervous  hyperesthesia  should  be  relieved  by  every  means  in  our 
power. 

The  means  for  furthering  these  ends  may  thus  be  presented : — 
Rest ; 

General  treatment ; 
Depletion  ; 

Emollient  vaginal  injections ; 
Alteratives. 

Rest The  patient  should  be  instructed  to  take  much  less  exercise 

than  usual,  to  lie  upon  her  bed  or  lounge  for  an  hour  every  day  about 
mid-day,  and  to  be  especially  quiet  during  menstrual  periods.  It  is  as  a 
general  rule  highly  improper  to  confine  her  to  bed,  for  many  women 
become  restive  under  the  confinement,  and  suffer  both  in  mind  and  body, 
the  sanguineous  and  nervous  systems  being  impaired  by  want  of  fresh  air. 
If  the  connective  tissue  be  so  much  affected  that  the  cervix  is  very  painful 
upon  pressure,  absolute  rest  upon  the  back  may  become  necessary,  but 
my  impression  is  that  deprivation  of  fresh  air  and  exercise  ordinarily 
does  more  harm  than  is  compensated  for  by  the  advantages  arising  from 
quietude.  Every  day  she  should  go,  unless  deterred  by  some  special 
cause,  into  the  open  air,  and  a  limited  amount  of  exercise  should  be  incul- 
cated as  a  means  of  keeping  up  the  general  health. 

"Within  a  few  years  Dr.  Weir  Mitchell  has  introduced  a  plan  for  treat- 
ing cases  of  neurasthenia  which  consists  of  complete  rest.  The  patient  is 
for  a  period  varying  from  six  weeks  to  three  months  kept  as  quiet,  upon 


TREATMENT.  331 

her  back  in  bed,  as  if  she  were  a  marble  statue  ;  or  rather,  I  should  say, 
as  far  as  voluntary  motion  is  concerned.  She  is  fed  by  an  attendant  who 
is  constantly  by  her  side,  and  is  not  allowed  even  to  lift  her  arms  from 
the  bed.  Meantime  she  is  very  thoroughly  nourished  by  milk,  animal 
broths,  malt,  cod-liver  oil,  eggs,  and  other  nutritious  substances,  every 
two  or  three  hours  ;  while  cutaneous  action  is  excited,  peripheral  circula- 
tion kept  at  a  maximum  of  activity,  metamorphosis  and  elimination  in- 
creased, and  muscular  strength  fostered,  by  manipulation,  passive  exercise, 
electricity,  and  kneading.  The  moral  faculties  are  likewise  supervised ; 
hysterical  symptoms  are  controlled  by  moral  suasion,  judicious  neglect, 
and  an  earnest  appeal  to  the  reason  of  the  patient  ;  and  the  mind  is  made 
to  feel  the  influence  of  alienation  from  home  influences  by  entire  seclusion 
from  friends  and  relatives. 

I  can  of  course  only  allude  to  this  plan,  which  observation  leads  me  to 
set  a  very  high  estimate  upon  in  the  treatment  of  special  cases,  and  would 
refer  the  reader  for  further  details  concerning  it  to  the  writings  of  Dr. 
Mitchell,1  and  to  an  excellent  article  by  Dr.  William  Goodell.2 

The  uterus  should  be  placed  at  rest  as  much  as  possible.  Its  natural 
tendency  under  these  circumstances  is  to  fall  from  its  position  ;  consequently 
all  pressure  should  be  removed  from  its  fundus  by  wearing  the  clothing 
loose,  sustaining  the  weight  of  the  skirts  by  attaching  them  to  the  upper 
garments,  so  as  to  have  the  shoulders  bear  the  burden,  and  uncompromis- 
ingly abolishing  the  corset. 

At  the  same  time  a  system  of  exercises  should  be  practised  by  the  pa- 
tient calculated  to  develop  the  power  of  the  abdominal  and  thoracic  mus- 
cles and  thus  restore  or  increase  the  retentive  power  of  the  abdomen. 
These  will  be  alluded  to  in  detail  under  the  head  of  displacements  of  the 
uterus. 

Abdominal  bandages  are  very  unpopular  with  many  practitioners,  who 
believe  that  they  absolutely  do  harm.  I  believe  otherwise,  and  regard 
them  as  great  adjuvants,  not  in  keeping  up  the  uterus,  but  in  supporting 
the  super-imposed  viscera,  which,  pressed  downwards  by  tight  clothing, 
and  badly  supported  on  account  of  the  relaxation  of  the  abdominal  walls, 
fall  directly  upon  the  fundus.  There  is  a  great  variety  of  abdominal  sup- 
porters. I  have  no  favorite,  for  one  will  accomplish  the  end  in  a  woman 
of  a  certain  figure  which  would  be  inappropriate  for  another.  That  one 
should  be  selected  which  absolutely  accomplishes  the  end  in  view,  namely, 
sustaining  the  viscera  and  supplementing  the  weakened  muscles  of  the 
abdomen. 

Sexual  intercourse  often  produces  bad  results  in  an  organ  which  is  so 
prone  to  congestion,  and  great  infrequency  and  caution  should  be  enjoined 
with  reference  to  it. 

1  Fat  and  Blood,  and  how  to  make  them. 

2  Nerve  tire  and  womb  ills,  Lessons  in  Gynecology. 


332  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

By  combining  all  these  means  we  do  all  in  our  power  to  place  the 
hyperplastic  uterus  at  rest  as  we  would  a  fractured  bone  or  enlarged 
testicle. 

General  Treatment The  diet  should  be  plain  and  unstimulating,  but 

at  the  same  time  nutritious,  and  in  every  way  calculated  to  maintain  the 
normal  state  of  the  blood.  Should  spanajmia  exist,  ferruginous  tonics, 
alone  or  combined  with  vegetable  tonics,  should  be  administered.  The 
bowels  should  be  kept  in  a  perfectly  normal  state,  and  the  skin  active. 
Specific  remedies  have  been,  and  are  still,  employed  by  some  practitioners 
for  diminishing  the  size  of  the  uterus.  Of  most  of  these  1  doubt  the  effi- 
cacy. During  the  state  of  enlargement,  that  is,  before  contraction  of  the 
exuberant  tissue  has  occurred,  ergot,  kept  up  for  a  considerable  time,  pro- 
duces good  results.  By  its  power  of  exciting  contraction  of  the  uterine 
tissue  it  diminishes  hyperemia,  and  lessens  the  bulk  of  the  uterus. 

European  writers  speak  in  high  terms  of  the  alterative  influences  of  the 
various  watering-places  and  baths  of  the  Continent,  as  those  of  Marienbad, 
Schwalbach,  Briicknau,  and  Kissingen,  in  Germany,  and  of  Saint  Sauveur, 
Barrages,  etc.,  in  France.  None  of  these  equal  in  reputation  the  waters 
of  Kreuznach  in  Germany,  the  curative  property  of  which  is  supposed  to 
depend  upon  the  bromide  of  magnesium  which  they  contain.  It  is  very 
probable  that  the  hygienic  and  social  influences  which  surround  these 
places  and  render  them  attractive,  are  to  be  credited  with  most  of  the 
good  that  they  do.  Aran,  after  admitting  that  the  water  of  Vichy  may 
exert  some  influence,  thus  pointedly  expresses  himself  with  reference  to  the 
others:  "Whatever  be  their  composition,  in  whatever  countries  they  may 
be  found,  I  know  of  no  work  in  which  we  can  find  an  approximation  to  a 
demonstration  in  their  favor." 

No  other  general  means  compares  in  result  with  a  change  of  abode  and 
corresponding  change  of  air,  habits,  and  associations.  A  removal,  for 
example,  to  the  seaside,  where  bathing  can  be  enjoyed,  a  sea  voyage,  or  a 
residence  at  an  agreeable  watering  place,  may  accomplish  much  good. 
Mental  depression  predisposes  to  and  aggravates  this  disease  most  markedly. 
Aran  goes  so  far  as  to  say  that  he  has  almost  invariably  found  it  present 
as  an  exciting  cause.  However  this  be,  cheerful  and  congenial  company 
certainly  proves  one  of  the  best  nervous  tonics  in  a  therapeutic  point  of 
view,  and  should  always  be  sought  for.  A  stay  in  a  well  regulated  hydro- 
pathic establishment,  where  the  patient  can  have  pure  air,  plain  and 
nutritious  food,  and  agreeable  society,  together  with  the  strict  attention  to 
the  general  rules  of  hygiene  which  characterizes  those  institutions,  will 
often  produce  the  best  effects. 

Depletion If  vaginal  touch  and  conjoined  manipulation  discover  the 

fact  that  the  uterus  is  tender,  the  occasional  abstraction  of  small  amounts 
of  blood  by  puncture  or  scarification  will  be  beneficial.  Not  more  than 
an  ounce  or  two  should  be  taken  at  once,  unless  amenorrhoea  be  a  symp- 


DEPLETION.  333 

torn.  In  case  this  be  so,  a  more  copious  abstraction  by  leeches,  (hiring 
the  menstrual  epoch,  will  often  give  great  relief.  At  times  leeches  then 
applied  to  the  cervix  will  give  great  pain  by  their  bites.  This  is  some- 
times so  severe  as  to  lead  to  the  apprehension  that  one  has  escaped  into 
the  cavity;  hence  it  is  important  that  they  should  be  counted  before  being 
placed  in  the  speculum,  and  on  their  removal  from  it. 

The  three  methods  by  which  local  depletion  of  the  cervix  can  be  best 
practised  are  leeching,  scarification,  and  cupping.  Three  or  four  large 
leeches,  or  a  sufficient  number  of  small  ones,  to  take  from  three  to  five 
ounces  of  blood,  may  be  applied  in.  the  following  manner:  A  cylindrical 
speculum,  of  sufficient  size  to  contain  the  entire  vaginal  portion  of  the 
cervix,  being  passed  and  the  part  thoroughly  cleansed,  a  small  pledget  of 
cotton,  to  which  a  thread  has  been  attached  for  removal,  should  be  placed 
within  the  os,  so  as  to  prevent  the  entrance  of  the  leeches  to  the  cavity 
above.  A  few  slight  punctures,  sufficient  to  cause  a  flow  of  blood,  should 
then  be  made  in  the  cervix,  and  all  the  leeches  to  be  employed  thrown  in, 
and  the  speculum  filled  at  its  extremity  by  a  dossil  of  cotton  pushed 
towards  the  bleeding  surface.  The  speculum  should  be  watched  until 
they  cease  sucking,  for  if  left  for  a  very  short  time,  even  with  the  mouth 
of  the  instrument  filled  with  cotton,  they  will  escape.  After  their  removal 
all  clots  of  blood  should  be  removed  by  a  sponge  or  a  rod  wrapped  with 
cotton,  the  speculum  withdrawn,  a  large  sponge  squeezed  out  of  warm 
water  placed  over  the  vulva,  and  the  patient  directed  to  remain  perfectly 
quiet.  Should  scarification  be  employed,  a  very  sharp  and  narrow  bis- 
toury or  tenotomy  knife  may  be  introduced  within  the  os,  and  drawn  out- 
ward towards  the  vaginal  edges  of  the  cervix  so  as  to  sever  all  the  super- 
ficial vessels  over  which  it  passes.  I  would  recommend,  in  preference  to 
this  plan,  acupuncture,  which  may  be  performed  by  an  ordinary  three-sided 
surgical  needle  held  in  the  grasp  of  a  pair  of  forceps,  or,  still  better,  by  a 
little  spear,  the  invention  of  Dr.  Buttles,  of  this  city. 

Fig.  124. 


Buttles's  spear-pointed  scarificator. 

This  little  instrument,  when  plunged  about  one-sixteenth  of  an  inch 
into  the  cervix  and  given  a  rapid  half  turn  before  removal,  causes  a  very 
free  flow  of  blood  should  congestion  exist.  If  a  sufficient  flow  does  not 
occur  from  three  or  four  of  its  punctures,  this  can  be  caused  by  dry  cup- 
ping the  cervix  by  a  very  simple  instrument,  made  of  vulcanite,  which  is 
introduced  through  the  speculum,  the  medium  size  of  the  cylindrical 
variety  being  large  enough  to  admit  it.  Being  passed  up  to  the  cervix, 
the  piston  is  retracted,  and  so  perfect  is  the  working  of  these  instruments, 
when  constructed  of  vulcanite,  that  a  complete  vacuum  is  produced.     By 


334  AREOLAR    HYPERPLASIA    OR    CHRONIC    METRITIS. 

using  this  for  a  few  minutes,  and  then  puncturing,  with  Buttles's  spear, 
from  two  to  four  ounces  of  blood  may  readily  be  drawn.  The  exhauster 
should  not  be  used  after  puncturing,  but  before  it.  All  that  will  be  neces- 
sary afterwards  will  be  to  pass  a  moist  sponge,  attached  to  a  sponge- 
holder,  over  the  punctured  surface  so  as  to  prevent  clotting  in  the  mouths 
of  the  bleeding  vessels.  Dr.  John  Byrne,  of  Brooklyn,  has  drawn  especial 
attention  to  still  another  method,  which  in  some  cases  answers  an  excellent 
purpose.  It  consists  in  passing  a  long,  delicate  blade  up  the  os  internum, 
and  cutting  through  the  mucous  membrane,  its  bloodvessels,  and  the  super- 
ficial layer  of  muscular  tissue,  as  it  is  withdrawn  through  theos  externum. 
Local  depletion  by  one  of  these  methods  should  be  practised  cautiously, 
the  patient  for  twenty-four  hours  after  its  adoption  being  kept  perfectly 
quiet  in  bed. 


Hard  rubber  cylinder  for  dry  cupping  the  cervix  uteri. 

It  is  surprising  to  observe  how  steadily  depletion  by  all  these  means  has 
been,  during  the  last  ten  years,  going  out  of  vogue  in  New  York.  Many 
gynecologists  with  large  practices  have  entirely  given  it  up,  and  in  the 
Woman's  Hospital  it  has  almost  completely  passed  out  of  use.  It  must  be 
remembered,  however,  that  the  same  statement  would  hold  good  in  refer- 
ence to  abstraction  of  blood  in  every  other  department  of  medicine. 

Vaginal  Injections — A  great  deal  of  advantage  accrues  in  these  cases, 
from  the  systematic  use  of  very  copious  vaginal  injections  of  water  as  hot 
as  the  patient  can  bear  them.  They  should  be  employed  for  from  fifteen 
to  twenty  minutes  at  a  time  and  once  in  every  twelve  hours.  Their  use 
quiets  pain,  improves  the  pelvic  circulation,  removes  irritating  secretions, 
and  unquestionably  stimulates  the  absorption  of  effused  material. 

Local  Alteratives. — The  best  local  alterative  is  the  compound  tincture 
of  iodine,  which,  by  means  of  a  brush  of  pig's  bristles,  should  be  carried 
up  to  the  os  internum  or  even  to  the  fundus,  should  endometritis  exist, 
and  over  the  whole  cervix ;  then,  waiting  for  complete  drying,  this  process 
should  be  repeated.  After  these  applications  a  wad  of  cotton,  to  which  a 
string  has  been  attached  in  such  a  way  as  to  leave  its  surface  flat,  should 
be  saturated  with  glycerine  and  laid  against  the  cervix.  This  acts  as  a 
local  hydragogue,  and  disgorges  the  tissues.  '  These  local  applications 
should  be  repeated  once  a  week,  but  others  should  be  made  oftener  by  the 
patient  herself  by  means  of  vaginal  injections,  by  which  the  drugs  just 
mentioned  may  be  brought  in  contact  with  the  cervix. 

Should  it  appear  to  the  practitioner  that  persistent  hyperemia  requires 
more  energetic  means  than  those  mentioned,  resort  may  be  had  to  counter- 


LOCAL    ALTERATIVES.  835 

irritants  which  vesicate  and  destroy  the  mncous  membrane  of  the  vaginal 
cervix,  and  thus  cause  a  free  flow  of  serum.  Such  cases  grow  smaller 
and  smaller  in  my  practice  as  I  grow  older  in  experience,  and  although  I 
admit  the  occasional  necessity  of  these  means,  I  caution  the  reader  against 
a  constant  or  too  early  resort  to  their  use.  They  cannot  diminish  the 
absolute  size  of  the  enlarged  organ,  and  should  not  be  used  with  any  such 
view.  They  can  remove  congestion  and  nervous  exaltation,  and  in  cer- 
tain exceptional  cases  may  be  employed  for  these  purposes. 

One  of  the  best  methods  for  practising  counter-irritation  upon  the  cer- 
vix uteri  is  by  blistering,  a  means  for  which  we  are  indebted,  I  believe,  to 
Aran,  of  Paris.  To  blister  the  cervix,  a  large  cylindrical  speculum  should 
be  used  which  will  take  the  whole  part  into  its  field.  The  cervix  having 
been  cleansed  and  dried  by  a  soft  sponge  or  dossil  of  cotton,  a  camel's- 
hair  brush  is  dipped  into  vesicating  collodion,  which  consists  of  ordinary 
collodion,  commonly  known  as  liquid  cuticle  in  this  country,  containing  in 
suspension  cantharides,  and  painted  over  the  whole  vaginal  cervix,  no 
effort  being  made  to  avoid  the  os.  There  are  two  preparations  of  vesi- 
cating collodion,  one  made  with  ether,  the  other  with  acetic  acid.  The 
second  is  the  more  powerful  and  the  less  likely  to  affect  the  vagina.  In 
a  few  seconds  after  it  is  painted  on  the  cervix,  it  forms  a  hard,  insoluble 
covering,  upon  which  two  or  three  other  coats  maybe  at  once  applied. 

The  whole  is  then  exposed  to  the  air  by  keeping  the  speculum  in  place 
for  a  few  minutes,  a  stream  of  cold  water  projected  upon  it,  to  prevent  any 
escape  into  the  vagina,  and  the  process  is  finished.  In  from  eight  to 
twelve  hours  the  epithelial  covering  of  the  cervix  is  entirely  removed  by 
this,  and  a  free  flow  of  serum  takes  place  as  from  a  blister  elsewhere  ap- 
plied. After  this  the  patient  should  be  kept  perfectly  quiet  for  several 
days,  cleansing  the  vagina  by  warm  injections,  and  as  soon  as  the  dis- 
charge shows  a  tendency  to  cessation,  the  blistering  should  be  repeated. 
The  only  objections  to  this  method  of  counter-irritation  are  the  liability  to 
vaginitis  and  cystitis  from  escape  of  the  blistering  fluid  into  the  vagina 
and  mouth  of  the  urethra,  which  can  readily  be  avoided,  and  the  pain 
which  is  experienced  in  some  cases  while  vesication  is  taking  place. 

After  blistering,  pledgets  of  cotton  saturated  with  glycerine  should  be 
applied  for  the  hydragogue  effects  of  that  drug. 

Vesication  may  be  easily  produced  by  still  another  method  which  is  both 
effectual  and  simple.  By  means  of  a  solid  stick  of  nitrate  of  silver,  wdiich 
is  rubbed  gently  over  the  whole  vaginal  portion  of  the  cervix,  its  epithelial 
covering  is  destroyed,  soon  sloughs  off,  and  leaves  a  granulating  surface, 
which  may  be  dressed  with  any  of  the  alterative  substances  mentioned 
above,  or  with  glycerine. 

Mild  and  lacking  in  vigor  as  this  course  may  appear,  let  any  one  test  it 
side  by  side  with  the  plan  of  using  the  acid  nitrate  of  mercury,  potassa 
fusa,  and  potassa  cum  calce,  and  the  actual  cautery  ;  of  swabbing  out  the 


336  GRANULAR    AND    CYSTIC 

uterine  cavity  with  chemically  pure  nitric  acid,  or  of  leaving  a  piece  of 
solid  nitrate  of  silver  to  melt  within  it ;  and,  unless  his  experience  greatly 
differ  from  mine,  he  will  feel  that  in  the  former  he  has  reached  a  resting 
place  for  his  faith  in  the  treatment  of  the  most  important  of  all  the  forms 
of  uterine  disease.  He  will  see  proof  daily  spring  up  before  him  that  his 
capacity  for  benefiting  his  patients  has  greatly  increased,  while  his  liability 
to  injuring  them  has  as  markedly  diminished. 

Dr.  August  Martin,  of  Berlin,  advocates  amputation  of  one  lip  of  the 
cervix  for  the  induction  of  a  species  of  involution  in  cases  of  areolar  hyper- 
plasia. Some  time  ago  he  reported  seventy-two  such  operations,  in  only 
seven  of  which  did  any  inflammatory  symptoms  show  themselves,  and 
which  were  invariably  followed  by  a  diminution  in  the  capacity  of  the  uterus 
of  from  two  to  three  centimetres.  In  a  discussion  which  followed  a  paper 
by  Martin,  Kehrer,  Schrceder,  and  Olshausen  agreed  with  it.  This  method 
possesses  none  of  the  advantages  of  trachelorrhaphy,  to  which  it  is  inferior 
in  every  respect.  Both  operations  are  usually  employed  where  laceration 
of  the  cervix  exists  as  a  cause  of  the  hyperplasia. 


CHAPTER    XXI. 

GRANULAR  AND  CYSTIC  DEGENERATION  OF  THE  CERVIX  UTERI. 

No  subject  in  connection  with  gynecology  has  attracted  more  attention 
within  the  past  fifty  years  than  inflammatory  ulceration  of  the  cervix  uteri. 
Until  a  comparatively  late  period  it  was  fully  believed  in,  but,  as  more 
careful  observation  has  been  practised,  the  fact  has  been  recognized  that 
unless  affected  by  direct  pressure  or  friction  from  some  solid  body  the  cer- 
vix uteri  is  little  prone  to  simple  ulceration.  It  is,  of  course,  everywhere 
admitted  that  cancerous  and  syphilitic  ulcerations  may  affect  this  part, 
but  no  one  would  propose  to  style  these  inflammatory  ulcers.  It  is  like- 
wise admitted,  that  in  a  prolapsed  uterus,  friction  against  a  pessary  or  the 
clothing,  commonly  produces  true  inflammatory  ulceration.  But  these 
admissions  do  not  touch  the  point  at  issue,  and  it  is  fully  agreed  to-day 
that  the  condition  lately  styled  inflammatory  ulceration,  by  Dr.  Henry 
Bennet  and  his  school,  was  not  one  of  ulceration  at  all,  but  one  of  exube- 
rant growth  of  the  tissues  of  the  cervix  with  or  without  laceration  of  this 
part,  which  is  much  more  correctly  described  under  the  names  which  head 
this  chapter. 

It  not  unfrequently  happens  that  one  symptom  of  a  disease  will  so  dis- 
tress and  harass  a  patient  that  remedial  measures  must  be  entirely  directed 
to  it,  although  the  practitioner  be  aware  of  the  fact  that  it  depends  on  dis- 


DEGENERATION  OF  THE  CERVIX  UTERI.        337 

eases  elsewhere  located.  An  example  of  this  is  frequently  presented  in 
the  morbid  state  under  consideration,  which,  in  itself,  proves  so  annoying 
by  its  profuse  discharge,  and  interference  with  the  functions  of  the  uterus 
and  with  locomotion,  as  to  call  for  prompt  relief. 

The  vaginal  surface  of  the  cervix  uteri  is  covered  by  a  smooth  mucous 
membrane,  which  is  continuous  below  with  that  of  the  vagina,  and  extend- 
ing through  the  cervical  canal  joins  that  of  the  body,  which  differs  widely 
from  it,  at  the  os  internum.  This  membrane  is  covered  over  by  numerous 
papilla?  which  become  visible  when  a  sufficiently  strong  glass  is  used.  One 
or  more  slender  bloodvessels  pass  into  each  and  form  at  their  extremities 
vascular  loops,  then  return,  and  at  their  bases  pass  into  adjoining  ones. 
They  are  completely  covered  by  pavement  epithelium  and  basement  mem- 
brane. Throughout  the  cervical  canal  mucous  crypts  or  follicles  exist,  which 
are  likewise  found  scattered  over  the  vaginal  portion  of  the  cervix,  and 
even  within  the  cavity  of  the  uterus  itself.  The  diseases  of  two  of  these 
elements  of  cervical  mucous  membrane  are  now  to  en«a<re  our  attention. 


o    o 


Granular  Degeneration  of  the  Cervix. 

Definition — This  condition,  which  has  been  described  under  the  names 
of  erosion  of  the  cervix,  granular  ulcer,  and  epithelial  abrasion,  consists, 
as  its  name  implies,  in  the  development  of  a  surface  of  granular  character 
on  the  smooth  face  of  the  cervix  and  just  within  the  os. 

Frequency. — It  is  an  affection  of  great  frequency,  attending  all  the  dis- 
eases of  the  uterus  which  result  in  leucorrhcea,  and  being  commonly  a  con- 
comitant of  most  of  the  diseased  conditions  of  the  parenchyma  and  lining 
membrane.  Very  often  it  exists  for  a  length  of  time  without  any  suspicion 
of  its  presence  arising  in  the  mind  of  patient  or  physician,  and  sometimes 
without  causing  symptoms  which  prove  in  any  great  degree  annoying. 
At  others,  grave  constitutional  signs  may  be  traced  to  it  and  entirely  re- 
moved by  its  cure. 

Causes The  predisposing  causes  are: — 

Enfeebled  "general  health; 

Spana?mia; 

The  scrofulous  diathesis ; 

The  syphilitic  diathesis. 
Those  which  are  exciting  are  the  existence  of — 

Displacements; 

Endometritis; 

Laceration  of  cervix; 

Areolar  hyperplasia ; 

Abuse  of  sexual  intercourse; 

Vaginal  leucorrhoea; 

Pessaries  which  touch  the  vaginal  face  of  the  cervix. 
22 


338  GRANULAR    AND    CYSTIC 

From  this  array  of  causes  it  will  appear  that  it  is  rarely  a  disease  which 
stands  alone,  but  that  it  is  usually  engrafted  upon  some  other  affection  of 
greater  moment.  Although  this  is  true,  it  will  not  do  in  practice  to  carry 
the  view  too  far.  At  the  same  time  that  it  must  be  admitted  that  granu- 
lar degeneration,  even  of  aggravated  character  and  considerable  propor- 
tions, affecting  the  vaginal  face  of  the  cervix,  and  the  distal  extremity  of 
the  cervical  canal,  is  commonly  a  consequence  of  some  pre-existing  dis- 
ease, the  fact  must  not  be  lost  sight  of,  that  this  affection  of  itself  keeps 
up  a  hyperemia  in  the  subjacent  and  neighboring  parts  of  the  uterus,  and 
even  extends  a  reflex  influence  to  the  ovaries. 

By  almost  all  writers  upon  this  subject  since  Recamier's  time,  too  much 
stress  has  been  laid  upon  the  theory  that  it  depends  upon  an  "indurated 
and  hypertrophied  condition  of  the  parenchyma  of  the  cervix."  That  it 
results  from  this  no  one  would  deny,  but  it  is  equally  true  that  it  often 
arises  from  other  causes,  and  itself  induces  this  one.  In  general  terms  we 
may  say  that  it  is  usually  produced  by,  1st,  any  disorder  which  keeps  the 
mucous  membrane  of  the  cervix  constantly  bathed  with  ichorous  fluids  for 
a  length  of  time;  2d,  by  anything  which  keeps  up  friction  against  the  cer- 
vix; 3d,  by  any  influence  producing  and  perpetuating  congestion  of  the 
uterus.  Let  the  reader  turn  to  the  list  of  predisposing  causes  and  he  will 
see  that  they  are  just  such  as  to  favor  these  morbid  influences,  and  that 
the  exciting  ones  are  those  which  absolutely  produce  them.  For  example, 
displacements  keep  up  congestion  of  parenchyma  and  mucous  membrane, 
and  produce  uterine  leucorrhcea,  and  cause  friction  between  the  cervix, 
thus  engorged  and  excoriated,  and  the  vaginal  surface.  Hyperplasia  pro- 
duces displacement  with  all  its  results,  furnishing  in  advance  a  tissue 
peculiarly  prone  to  hyperemia,  and  already  abnormal  in  character.  Lacera- 
tion of  the  cervix  is  a  fruitful  source  of  cervical  hyperplasia,  and  the  ever- 
sion  of  mucous  membrane  which  attends  it  establishes  friction  which  results 
in  leucorrhoea  and  increase  of  hyperemia.  But  it  is  unnecessary  to  apply 
remarks  which  are  so  obvious  to  each  of  the  causes  mentioned. 

Before  Emmet  pointed  out  the  pathological  bearing  of  laceration  of  the 
cervix,  a  great  many  cases  of  that  accident  were  regarded  as  granular 
defeneration.  A  careful  differentiation  must  be  practised  with  reference 
to  the  two  affections,  while  at  the  same  time  a  proper  degree  of  weight 
should  be  given  to  the  fact  that  granular  degeneration  often  occurs  in  vir- 
gins and  involves  the  whole  vaginal  face  of  the  cervix. 

Symptoms Should  granular  degeneration  exist  with  but  trivial  disor- 
der of  the  uterus  of  any  other  kind,  very  few  symptoms  may  be  present. 
Indeed,  profuse  leucorrhoea  is  sometimes  the  only  one  of  which  the  patient 
will  complain.  The  fact  that  other  and  more  serious  symptoms  generally 
show  themselves,  is  a  corroboration  of  the  statement,  that  graver  disease 
of  the  uterus  constitutes  an  important  element  in  such  cases.     Ordinarily, 


DEGENERATION  OF  THE  CERVIX  UTERI.         339 

these  are  the  symptoms  which  will  be  noticed  in  a  case  of  the  more  serious 
kind: — 

Profuse  bloody  and  purulent  leucorrhoea; 

Pain  and  hemorrhage  after  intercourse; 

Menorrhagia  or  metrorrhagia ; 

Pain  on  locomotion ; 

Fixed  pain  in  back  and  loins; 

Tendency  to  spanaemia; 

Nervous  disorders  and  perhaps  hysteria. 

Physical  Signs — Vaginal  touch  alone  might  serve  as  a  diagnostic 
means,  for  by  it  the  cervix  is  felt  to  be  covered  by  a  velvety  or  granular 
surface,  which,  to  the  practised  finger,  is  at  once  recognizable.  But  the 
speculum  offers  the  fullest  corroboration  or  corrects  any  error  committed 
by  this  means.  By  it,  the  cervix,  more  especially  near  the  os,  is  seen  to 
be  covered  by  a  mass  of  pus,  which  being  removed  lays  bare  an  intensely 
red,  granular,  hemorrhagic-looking  space  of  greater  or  less  extent,  closely 
resembling  the  inner  surface  of  the  eyelids  when  affected  by  granular 
degeneration.  The  diseased  surface  does  not  appear  depressed  below,  but 
is  sometimes  even  elevated  above  the  surrounding  mucous  membrane. 

Course  and  Duration — The  disease  is  unlimited.  If  the  general  health 
improve,  it  is  possible  that  nature  may  effect  a  cure  without  the  aid  of 
local  treatment,  but  such  a  result  should  not  be  anticipated.  The  degene- 
rated surface  may  go  on  for  an  unlimited  time  pouring  out  pus,  and  thus 
greatly  impoverish  the  blood  and  cause  grave  constitutional  results. 

Pathology — According  to  Ruge  and  Veit,  the  maceration  of  the  cervi- 
cal mucous  membrane  in  ichorous  fluids  results  in  the  desquamation  of 
epithelium  to  such  an  extent  that  only  one  layer  of  cells  exists,  through  the 
diaphanous  structure  of  which  the  red  colored  tissue  beneath  is  visible,  with 
its  exaggerated  vascular  supply. 

Very  soon  from  the  epithelial  layer  prolongations  project  inwards,  dividing 
the  subjacent  tissue  into  villi  or  processes,  such  as  are  formed  in  the  vesi- 
cal and  uterine  mucous  membrane.  These  villous  projections  are  new 
formations,  not  hypertrophied  papilla?.  They  are  covered  with  epithelium, 
richly  supplied  with  superficial  bloodvessels,  and  liable  to  increase  to  large 
masses.  To  these  the  names  of  varicose  and  bleeding  ulcer  and  cock's- 
comb  granulation  have  been  given. 

Prognosis The  prognosis  in  this  affection  is  always  good,  though  it 

may  require  a  great  deal  of  time  to  effect  a  cure,  for  this  will  not  be  per- 
manent unless  that  of  the  coexisting  disease  be  accomplished. 

Treatment Before  treatment  for  this  condition  is  commenced,  let  me 

urge  the  practitioner  to  examine  carefully  as  to  whether  he  is  really  deal- 
ing with  a  case  of  granular  defeneration  or  with  one  of  cervical  laceration. 
The  two   conditions  closely  resemble  each  other ;  the  former  often  com- 


340  GRANULAR    AND    CYSTIC 

plicates  the  latter ;  and  a  treatment  which  is  appropriate  to  the  one  is 
utterly  insufficient  for  the  other. 

Granular  degeneration  heing  generally  a  secondary  disorder  engrafted 
upen  a  pre-existing  one,  before  treatment  is  adopted,  the  primary  disease 
should  be  sought  for,  and  both  should  be  treated  simultaneously. 

Should  displacement,  endometritis,  vaginitis,  or  areolar  hyperplasia 
exist,  attention  should  be  directed  to  their  relief  at  the  same  time  that 
this  one  of  their  results  is  treated.  It  may  be  asked,  if  this  be  true,  how 
is  it  that  the  mere  application  of  caustics  to  the  diseased  surface  will  so 
often  effect  a  recovery  without  regard  to  other  disease  ?  An  influence 
which  commonly  induces  granular  degeneration  is  congestion  of  the  mucous 
and  submucous  tissues  at  the  vaginal  extremity  of  the  cervix.  The  solu- 
tion of  continuity  to  which  the  caustics  are  applied,  acts,  after  their 
application,  as  an  issue,  and  they  by  derivative  and  alterative  influence 
effect  good.  It  is  precisely  in  accordance  with  this  principle  that  the 
practitioner,  if  called  to  treat  a  very  obstinate  case  of  cervical  hyper- 
plasia, which  is  unattended  by  such  solution  of  continuity,  creates  it  by 
abrading  the  surface  by  a  blister,  and  then  cures  the  issue  thus  caused  by 
such  caustics  as  the  nitrate  of  silver  or  chromic  acid.  It  is  common  to 
hear  physicians  remark  that  they  are  more  successful  in  treating  cases  of 
cervical  enlargement  accompanied  by  granular  degeneration,  than  those 
which  are  free  from  it.  The  key  to  the  explanation  is,  I  think,  the  one 
here  given. 

Having  presented  these  remarks  and  sufficiently  insisted  upon  their 
importance,  I  now  proceed  to  the  consideration  of  the  special  treatment 
of  the  condition  itself.  Before  commencing  treatment,  the  general  health 
should  receive  especial  attention  ;  those  tonics  and  hygienic  directions 
which  appear  best  suited  to  the  particular  case  being  given.  These  indi- 
cations should  from  the  commencement  be  as  far  as  possible  fulfilled :  1st, 
the  granular  surface  should  be  put  beyond  the  influence  of  friction ;  2d, 
it  should  be  protected  from  contact  with  ichrous  discharges  ;  3d,  a  steady 
alterative  influence  should  be  exerted  upon  it  by  local  applications ;  and 
4th,  congestion  of  the  uterus  and  of  the  especial  part  diseased  should  be 
prevented. 

To  accomplish  the  first  indication  the  uterus,  if  displaced,  should  be  put 
and  kept  in  position  by  a  well-fitting  pessary.  Even  if  its  axis  be  normal, 
it  is  often  excellent  practice  to  lift  it  out  of  the  pelvis  by  an  elastic  rinc. 
At  the  same  time  such  support  prevents  a  tendency  to  congestion  of  the 
organ,  and  may  be  rendered  more  effectual  by  careful  removal  of  all 
weight  from  the  abdomen,  by  tightly  fitting  or  heavy  clothing.  Let  no 
one  who  has  not  tried  this  as  an  adjuvant,  undervalue  it,  for  there  can  be 
no  question  of  its  great  utility. 

Free  use  of  copious  vaginal  injections  should  be  practised  twice  daily, 
to  remove  all  leucorrhceal  discharge,  and   should  this  arise  from  endome- 


DEGENERATION  OF  THE  CERVIX  UTERI.        341 

tritis,  that  condition  should  he  treated.  This  indication  may  further  he 
accomplished  hy  the  application  of  the  styptic  colloid  of  Richardson, 
which  consists  of  a  strong  solution  of  tannin  in  gun-cotton  collodion.  I 
know  of  no  means  hetter  calculated  than  this  to  accomplish  all  four  of  the 
indications  enumerated.  It  appears  to  act  not  only  as  a  direct  alterative, 
but,  forming  a  protective  crust  over  the  surface,  constitutes  for  it  a  shield 
against  friction  and  uterine  discharges,  while  at  the  same  time,  hy  its 
compression  of  the  excoriated  villi,  permeated  by  their  loops  of  vessels, 
and  of  the  submucous  tissue  with  its  increased  vascular  supply,  it  dimin- 
ishes local  congestion. 

The  nerves  governing  nutrition  and  circulation  in  the  part  should  be 
impressed  with  a  new  influence  by  direct  alterative  applications.  The 
best  solid  ones  are  the  stick  of  nitrate  of  silver  or  sulphate  of  copper  ;  and 
the  most  effectual  fluid  applications,  saturated  solution  of  carbolic  acid  ; 
chromic  acid  §ss  to  water  3J  ;  compound  tincture  of  iodine  ;  equal  parts 
of  tannin  and  glycerine,  left  in  contact  with  the  part  on  pledgets  of  lint 
or  cotton  ;  iodoform  ;  and  saturated  solution  of  persulphate  of  iron,  pure 
or  diluted  with  equal  parts  of  glycerine. 

It  is  a  good  routine  plan  to  begin  with  a  thorough  application  of  solid 
nitrate  of  silver,  and  follow  this  immediately  by  a  protective  coating  of 
styptic  colloid. 

When  an  exuberant  development  of  villi,  called  by  Evory  Kennedy,  I 
think,  cock's-comb  granulation,  exists,  it  is  well  to  snip  the  growths  as 
close  as  possible  to  the  mucous  membrane  by  a  pair  of  long-handled  scis- 
sors, or  even  to  scrape  the  surface  until  it  is  smooth,  by  means  of  the  steel 
curette,  before  applying  the  caustic.  After  this  the  same  substances  may 
be  used  as  for  ordinary  degeneration. 

Should  simple  eversion  of  the  cervix  exist,  the  hemorrhoidal  mucous 
membrane  should  be  at  once  removed  by  the  scissors  or  destroyed  by 
fuming  nitric  acid.  "When  this  is  excessive,  and  due  to  laceration  of  the 
canal  by  parturition,  the  condition  may  be  cured  by  an  operation  which 
consists  in  paring  with  long  scissors  the  edges  of  the  cervical  fissure,  and 
passing  deep  sutures  of  silver  wire  so  as  to  approximate  them  thoroughly. 
By  this  means  the  os  is  restored  to  its  integrity,  and  the  everted  mucous 
surfaces  being  placed  face  to  face,  friction  against  them  is  prevented. 

The  last  indication  in  enumeration,  but  not  in  importance,  is  the  pre- 
vention of  congestion,  local  and  general.  To  a  certain  extent  this  is 
accomplished,  locally,  by  all  the  alterative  and  astringent  applications 
alluded  to,  and  the  same  thing  may  be  furthered  by  vaginal  suppositories 
and  injections.  Should  any  case  prove  very  obstinate,  this  end  may  be 
more  decidedly  attained  by  taking  a  sharp-pointed,  curved  bistoury,  and 
beginning  as  high  up  the  cervix  as  the  disease  extends,  cutting  through 
the  mucous  membrane  and  submucous  tissue,  extending  the  incision  out- 
side the  os  as  far  as  the  surfac©  is  affected.     Five  or  six  such  superficial 


342  GRANULAR    AND    CYSTIC 

and  painless  incisions  sever  the  network  of  little  vessels  in  the  submucous 
tissue,  and,  for  the  time  afr  least,  interfere  with  the  circulation. 

Congestion  of  the  whole  uterus  is  greatly  relieved  by  removal  of  weight 
from  it  by  abdominal  and  skirt  supporters  ;  avoidance  of  muscular  efforts  ; 
the  use  of  a  pessary ;  careful  regulation  of  the  bowels ;  rest,  especially 
during  menstruation  ;  and  the  use  of  copious  warm  vaginal  injections. 

Applications  should  be  made  not  only  by  the  physician,  who  will  pro- 
bably use  the  speculum  not  oftener  than  once  a  week,  but  also  by  the 
patient,  who  should  make  them  daily  by  injections  and  suppositories. 
The  former  should  be  thus  employed :  every  night  and  morning  a  gallon 
of  warm  water,  containing  one  ounce  of  glycerine  and  one  drachm  of 
sulphate  of  zinc,  or  two  of  sulphate  of  alum,  acetate  of  lead,  or  tannin, 
should  be  injected  for  a  period  varying  from  ten  to  twenty  minutes.  Or 
if  it  be  found  necessary  to  employ  a  stronger  astringent  solution,  a  gallon 
of  pure  water  may  be  used  first,  for  the  time  mentioned,  and  then  a  medi- 
cated solution,  one  quart  in  amount,  be  used  for  a  short  time  afterwards. 

Vaginal  suppositories  are  by  some  practitioners  employed  under  these 
circumstances.  A  suppository  may  be  made  to  contain  three  grains  of 
oxide  of  zinc,  or  of  sulphate  of  alum ;  ten  grains  of  mercurial  ointment ; 
five  grains  of  iodide  of  lead  ;  or  two  grains  of  tannin.  To  any  one  of 
these,  should  an  anodyne  be  needed,  one  grain  of  the  extract  of  belladonna, 
or  of  opium,  may  be  added.  These  substances  may  be  made  into  a  mass 
with  powdered  gum  tragacanth,  starch,  or  slippery  elm,  and  glycerine,  and 
the  whole  covered  with  cocoa  butter.  They  may  be  introduced  by  the 
finger,  but  by  the  use  of  the  vaginal  suppository  tube,  elsewhere  mentioned, 
there  is  much  greater  certainty  of  their  coming  in  contact  with  the  dis- 
eased surface.     Suppositories  may  be  employed  once  or  twice  a  day. 

Surprise  may  be  felt  at  the  small  amount  of  medicinal  substance  which 
I  propose  to  add  to  each  suppository.  A  great  deal  of  discomfort  often 
arises  from  larger  doses  than  I  have  mentioned.  I  have  repeatedly  seen 
patients  for  whom  two  grains  of  tannin  thus  administered  was  too  large  a 
dose,  and  who  had  in  consequence  to  cut  each  suppository  in  half  before 
employing  it. 

Cystic  or  Follicular  Degeneration  of  the  Cervix. 

Definition. — This  form  of  disease,  though  not  so  frequent  as  that  last 
mentioned,  is  by  no  means  rare.  It  consists  in  an  inflammation  of  mucous 
follicles,  which  resemble  those  of  the  cervical  canal,  and  which  are  scat- 
tered over  the  vaginal  face  of  the  cervix,  and  exist  even  in  the  cavity  of 
the  womb.  "The  cervical  mucous  cysts,"  says  Farre,  "are  lined  by 
epithelium  and  basement-membrane.  They  contain  a  small  quantity  of 
mucus  together  with  granule-cells.  Those  upon  or  near  the  margin  of  the 
os  uteri  may  be  sometimes  observed  to  contain  short  papillae  within  their 


DEGENERATION    OF    THE    CERVIX    UTERI. 


343 


Fio.  12fi. 


Cystic  degeneration  of  the 
cervix. 


margin."     A  recollection  of  these  facts  is  essential  to  a  full  understanding 
of  the  stages  of  this  form  of  degeneration. 

Pathology. — Follicular  disease  of  the  cervix  shows  three  entirely  dif- 
ferent phases :  1st.  A  number  of  vesicles,  equal  in  size  to  a  millet  seed 
and  filled  with  a  fluid  like  honey,  is  noticed  covering  the  part.  These 
are  due  to  repletion  from  retention  of  the  secretion  of  the  follicles.  2d. 
These  cysts  are  seen  open,  i.  e.,  they  have  burst, 
and  a  depression  marks  the  former  site  of  each. 
3d.  The  papillae  which  they  contain  undergo 
hypertrophy  and  cause  the  appearance  of  red, 
elevated,  liemorrhagic-looking  tubercles  in  place  of 
the  depressions  just  mentioned.  For  the  thorough 
knowledge  of  this  subject  we  are  indebted,  as  for 
so  much  else  relating  to  the  anatomy  and  pathology 
of  the  uterus,  to  Dr.  Arthur  Farre.  Usually  the 
cervix  is  seen  studded  over  by  little  globular 
bodies  about  as  large  as  a  hemp  seed,  with  here 
and  there  a  depression,  and  here  and  there  a  promi- 
nence of  red  and  irritable  looking  character. 

Synonyms — It  will  now  be  readily  appreciated  why  a  variety  of  names 
should  have  been  applied  to  this  disease  when  examined  at  different  staaes. 
Follicular  disease  is  supposed  to  be  the  source  of  the  eruptive  affections 
described  by  authors  as  acne,  herpes,  and  aphthae  of  the  uterus. 

Causes Anything  which  keeps  up  congestion  in  the  cervical  mucous 

membrane  may  give  rise  to  this  affection  of  the  mucous  glands  of  the 
vaginal  cervix.     Among  the  chief  are  : — 

Cervical  endometritis ; 

Granular  degeneration  ; 

Cervical  hyperplasia  ; 

Laceration  of  the  cervix. 
Prognosis — If  a  few  scattered  cysts  appear,  the  prognosis  is  decidedly 
favorable ;  but  in  certain  rare  cases,  where  the  whole  of  the  extremity  of 
the  cervix  is  filled  by  them,  nothing  but  amputation  of  the  part  containing 
them  accomplishes  cure. 

Treatment. — The  contents  of  all  the  cysts  should  be  evacuated  by  a 
bistoury,  and  their  cavities  thoroughly  cauterized  by  a  sharp  point  of 
nitrate  of  silver,  chromic  acid,  or  the  acid  nitrate  of  mercury.  Should 
the  second  or  third  stage  exist,  the  diseased  surface  should  be  treated 
upon  very  much  the  same  plan  as  that  advised  for  granular  degeneration. 
Should  a  great  amount  of  cystic  degeneration  exist,  and  cure  not  follow 
evacuation  and  cauterization  of  the  cysts,  the  vaginal  face  of  the  cervix 
should  be  removed  by  the  galvano-caustic  wire,  or  by  bistoury  or  scissors. 
Here,  as  in  cervical  endometritis  of  cystic  character,  the  rule  of  surgery 
which  inculcates  the  ablation  of  a  part  which  is  the  habitat  of  a  disease 
which  proves  incurable  by  minor  means,  should  be  followed. 


344      SYPHILITIC  ULCER  OF  THE  CERVIX  UTERI. 


CHAPTER    XXII. 

SYPHILITIC  ULCER  OF  THE  CERVIX  UTERI. 

Frequency. — Syphilis  may  affect  the  cervix  uteri  either  as  a  primary 
or  secondary  disorder,  though  in  neither  form  is  it  by  any  means  common. 
It  is  now  a  settled  fact  that  true  chancre  may  locate  itself  upon  the  cervix, 
but  not  the  less  certain  is  it  that  it  rarely  does  so.  I  have  seen  but  one 
case  which  I  felt  satisfied  was  of  this  character.  This  was  proved  by 
inoculation,  the  most  certain  way  in  which  a  strictly  reliable  conclusion 
can  be  arrived  at,  and  by  corroborative  evidence  existing  in  the  presence 
of  syphilitic  roseola  without  primary  disease  elsewhere.  Dr.  Bennet* 
states  that  in  his  own  practice  it  has  been  very  rarely  met  with,  and 
quotes  in  confirmation  of  his  own  experience  that  of  Ricord,  Cullerier, 
Gibert,  Diiparcque,  and  others.  M.  Bernutz,  who  has  made,  according 
to  Becquerel,2  a  special  study  of  this  subject  in  the  hospitals  of  Paris, 
describes  chancres  of  the  os  minutely,  dividing  them  into  Hunterian, 
diphtheritic,  and  ulcerous,  which  resemble  phagedenic  very  closely.  With 
regard  to  secondary  affections  on  the  cervix,  there  has  been  considerable 
discussion,  some  regarding  them  as  quite  common,  others  as  very  rare. 
Becquerel,  after  careful  research  in  l'Ourcine  Hospital  at  Paris,  was  con- 
vinced of  their  occurrence,  and  Bernutz  describes  mucous  patches,  vege- 
tations, erosions,  tubercles,  and  gummy  tumors.  I  know  of  no  more 
significant  evidence  of  the  rarity  of  these  affections  upon  the  cervix  than 
the  fact,  that  in  a  recent  work  upon  syphilis,  a  work  remarkable  for  the 
thorough  and  comprehensive  style  with  which  it  deals  with  all  relating  to 
that  subject,  almost  no  mention  is  made  of  syphilitic  affections  of  the  cervix. 
I  allude  to  the  work  of  the  late  Prof.  Bumstead.3  The  author  investi- 
gates the  character  of  syphilis  when  affecting  all  parts  of  the  body,  even 
the  lachrymal  sacs,  the  membrana  tympani,  etc.,  but  nowhere  is  any 
mention  made  of  the  disease  appearing  on  the  cervix,  except  a  cursory 
statement,  that  at  Bellevue  Hospital  he  had  seen  some  remarkable  in- 
stances of  mucous  patches  thus  located.  The  sign  of  the  secondary  dis- 
order which  we  would  most  naturally  expect  to  find  in  this  site  would  be 
the  mucous  patch,  as  it  is  one  of  the  most  frequent  of  all  the  manifesta- 
tions of  that  stage  ;  but  we  are  informed  by  MM.  Davasse  and  Deville,4 

1  Bennet  on  the  Uterus,  p.  350.  *  Mai.  de  l'Uterus,  vol.  i.  p.  169. 

*  Bumstead  on  Venereal  Diseases. 

4  Davasse  and  Deville,  Des  Plaques  Muqueuses :  Arch.  G6n.  de  Med.,  1845,  t. 
ix.  et  x. 


SYPHILITIC  ULCER  OF  THE  CERVIX  UTERI.       34") 

that  of  one  hundred  and  eighty-six  women  affected  by  syphilis,  and  ex- 
amined in  reference  to  the  location  of  its  lesions,  they  were  found  on  the 
cervix  uteri  bat  once. 

Course  and  Termination. — The  primary  affection  being  located  on  the 
cervix,  the  general  system  becomes  affected  as  from  a  chancre  on  any  other 
part,  and,  as  M.  Gosselin  has  pointed  out,  instead  of  passing  off  rapidly, 
as  it  sometimes  does,  it  may  assume  the  fungous  type.  During  its  course 
the  cervical  chancre  has  a  marked  tendency  to  become  covered  by  false 
membrane,  which  Robert1  first  noted,  and  Bernutz  subsequently  corrobo- 
rated. Unless  a  fact  corroborated  by  Forster2  be.  carefully  borne  in  mind 
by  the  diagnostician,  a  grievous  error  may  occur  in  the  differentiation  of 
this  form  of  ulcer  from  malignant  disease.  He  declares  that  syphilitic 
ulcers  sometimes  destroy  tissue  so  freely  as  to  penetrate  into  the  bladder 
or  rectum. 

Differentiation For  evident  reasons  this  is  a  matter  of  great  import- 
ance, not  only  as  regards  therapeutics,  but   because  it  may  involve  a  deli- 
cate legal  question  affecting  the  chastity  of  the  woman. 
These  are  the  means  of  diagnosis  in  cases  of  chancre  : — 

Border  of  ulcer  precipitous  ; 

Surface  of  ulcer  depressed  ; 

Great  tendency  to  bleed  ; 

Great  tendency  to  false  membranous  covering  ; 

Rapid  development  of  constitutional  symptoms  ; 

Early  appearance  of  roseola  ; 

Transmission  by  inoculation. 
All  of  these  signs  are  of  value,  but  the  only  ones  upon  which  a  positive 
opinion  could  be  based  are  the  last  three. 

Secondary  eruptions,  as  for  example,  mucous  patches,  vegetations,  etc., 
which  appear  here  will  be  known  by 

Their  rapid  development ; 

Their  connection  with  constitutional  signs  ; 

Simultaneous  affection  of  the  vagina  ; 

Absence  of  chronic  cervical  inflammation  ; 

The  peculiar  appearance  of  secondary  eruptions. 
Treatment — This  will  consist  in  cases  of  chancre  of  the  ordinary  treat- 
ment adopted  when  such  an  ulcer  affects  any  other  part.  In  cases  of 
secondary  affections  the  patient  should  be  put  upon  a  mercurial  course, 
the  surface  cauterized,  and  subsequent  dressings  made  of  mercurial  pre- 
parations, of  which  the  black  or  yellow  wash,  mercurial  ointment,  and 
calomel,  are  the  best. 

1  Aran,  Mai.  de  l'Uterus,  p.  524.  a  Klob,  op.  cit.,  p.  243. 


>46  UTERINE    FUNGOSITIES. 


CHAPTER  XXIII. 

UTERINE  FUNGOSITIES. 

History. — The  fact  that  the  lining  membrane  of  the  uterus  becomes 
covered  over  to  a  greater  or  less  degree  with  fungous  masses,  which  have 
a  marked  tendency  to  bleed,  was  announced  by  Recamier,  who  not  only 
described  them,  but  gave  us  the  best  method  yet  devised  for  their  re- 
lief. After  attention  was  called  to  the  subject  by_him,  theses  were 
written  upon  it  in  Paris  and  Strasbourg,  by  Rouyer  and  Goldschmidt,  and 
the  subject  attracted,  a  great  deal  of  notice  in  France,  and  received  the 
attention  of  such  men  as  Marjolin,  Robert,  Trousseau,  Nelaton,  Maison- 
neuve  and  Nonat,  who  not  only  adopted  Recamier's  pathological  views  but 
endorsed  and  practised  his  method  of  treatment.  After  many  years  of 
trial  this  contribution  of  the  great  French  gynecologist  may  be  regarded 
as  by  no  means  the  least  valuable  of  the  many  which  he  has  made  to  this 
department.  For  a  long  time  kept  sub  judice,  it  has  of  late  years  found 
its  way  into  the  text-books. 

Definition — Uterine  fungosities  may  be  defined  as  fungous  projections 
from  the  endometrium,  the  result  of  prolonged  congestion  from  any  cause, 
or  of  the  organization  of  portions  of  placenta  remaining  attached  to  the 
surface.  Under  this  head,  of  course,  carcinoma  and  sarcoma  of  the  endo- 
metrium might  through  an  error  in  diagnosis  be  brought,  but  the  nature 
of  those  grave  disorders  being  once  recognized,  no  one  would  think  of 
classifying  them  under  it.  Upon  theoretical  grounds  objection  might  be 
raised  to  classifying  under  the  same  head  hyperplasia  of  the  lining  mem- 
brane of  the  uterus  and  remains  of  the  placenta,  but  as  the  symptoms  and 
treatment  of  the  two  conditions  are  identical,  and  there  is  no  means  of 
differentiating  one  from  the  other,  it  seems  better  for  practical  purposes  to 
consider  them  together. 

Frequency Fungoid  degeneration  of  the  endometrium  is  an  affection  of 

great  frequency ;  one  which  plays  the  part  of  an  important  factor  in  men- 
orrhagia  and  metrorrhagia,  and  which  often  saps  the  health  of  patients  in 
whom  its  existence  remains  for  years  unsuspected.  The  practitioner  who 
recognizes  the  important  bearing  of  this  subject  will  find  himself  prepared 
to  cope  with  many  cases  of  chronic  endometritis,  menorrhagia,  metror- 
rhagia, and  uterine  enlargement  which  before  proved  entirely  rebellious  to 
treatment. 

Synonyms The  disorder  is  sometimes  described  as  granular  hyper- 


SYMPTOMS.  347 

plastic,  or  polypoid   endometritis,   or,  as   Slavjanky  styles  it,  "  internal 
villous  metritis." 

Pathology. — Uterine  fungosities  will  usually  be  found  to  exist  as  a  con- 
sequence of  uterine  engorgement,  however  kept  up ;  or  of  abortion  or 
labor.  I  have  also  repeatedly  seen  them  in  young  women  at  the  age  when 
menstruation  is  establishing  itself,  and  found  them  under  those  circum- 
stances produce  a  most  excessive  and  dangerous  degree  of  hemorrhage. 
In  the  first  condition  mentioned,  prolonged  congestion  creates  a  hyper- 
genesis  of  tissue  which  results  in  hyperplastic  growths  upon  the  endome- 
trium. In  tl>e  second,  if  a  large  portion  of  placenta  remained  attached  in 
utero,  what  is  sometimes  styled  a  placental  polypus  would  be  created,  but 
small  portions  only  being  here  and  there  attached,  these  little  fungosities 
are  the  result.  In  the  third  condition,  the  great  impetus  given  by  puberty 
to  sexual  growth  in  the  developing  girl  seems  to  affect  the  uterine  lining 
so  as  to  produce  localized  hypertrophies  upon  its  surface. 

Under  the  microscope  these  growths  if  the  result  of  hyperplasia  and 
not  of  retention  of  small  portions  of  placenta  are  found  to  consist,  accord- 
ing to  Dr.  F.  Delaiield,  who  has  repeatedly  examined  them  for  me,  of 
hypertrophied  elements  of  the  mucous  membrane,  dilated  follicles,  enlarged 
bloodvessels,  and  exaggerated  cell  growth.  Sometimes  the  amount  of 
material  removed  at  one  time  will  amount  to  one,  two,  or  three  drachms, 
and  its  appearance  will  make  one  instinctively  dread  the  existence  of  a 
malignant  basis ;  but  the  microscope  will  commonly  even  in  such  cases 
convey  the  comforting  assurance  to  the  contrary. 

Causes. — The  causes  may  be  enumerated  as  follows : — 
Abortion  or  labor  at  full  term ; 
Endometritis ; 
Subinvolution; 
Laceration  of  the  cervix ; 
Uterine  displacement  of  any  variety  ; 
Fibromata,  submucous  or  interstitial. 
All  these,  except  the  first,  seem  to  produce  the  condition  by  exaggerating 
formative  development,  or  by  keeping  up  engorgement  of  the  uterine  lining 
membrane. 

Symptoms. — There  is  but  one  symptom  which  has  any  significance,  that 
is  uterine  hemorrhage.  This  may  consist  only  in  a  great  exaggeration  of 
the  menstrual  flow,  or  in  profuse  metrorrhagia.  Whenever  either  or  both 
of  these  is  present,  without  other  assignable  cause,  these  growths  should  be 
suspected.  For  example,  a  patient  has  lost  a  great  deal  of  blood  from  the 
uterus,  and  an  abnormal  condition  is  strongly  suspected  as  the  cause  of 
the  excessive  flow  ;  no  solution  of  continuity  is  found  to  exist,  no  neoplasm 
of  any  kind  is  discovered,  and  no  large  portion  of  placenta  is  supposed  to 
be  in  utero ;  under  these  circumstances  fungosities  should  always  be  sus- 
pected, and  their  existence  determined  by   physical   examination.     The 


348  UTERINE    FONGOSITIES. 

method  of  deciding  the  question  is  so  simple  that  it  should,  under  these 
circumstances,  be  unhesitatingly  employed. 

Physical  Signs. — Fungosities  being  suspected  to  exist,  the  patient 
should  be  examined  with  Sims's  speculum.  After  its  introduction,  the 
cervix  should  be  held  by  the  tenaculum,  and  if  the  os  externum  or  cervical 
canal  be  very  small,  it  should  be  gently  opened  by  the  introduction  of  two 
or  three  graduated  uterine  dilators  until  it  will  admit  the  little  wire  curette 
to  be  shown  further  on  in  this  chapter.  An  ordinary  looped  wire  answers 
very  well,  and  I  have  often  made  a  loop  of  a  lady's  hairpin,  bound  it  with 
waxed  thread  in  the  bite  of  the  forceps,  and  employed  that. 

All  being  now  prepared,  the  loop  of  the  wire  curette,  or  the  loop  of  wire, 
is  passed  in  and  drawn  gently  down  the  anterior  face  of  the  uterine  cavity, 
then  of  the  posterior,  and  then  of  each  horn.  As  it  is  withdrawn  after 
making  each  exploration,  it  is  examined  to  see  if  it  has  dislodged  a  fun- 
gosity.  If  there  be  any  within  the  cavity,  and  the  instrument  be  not  held 
in  very  unskilful  hands,  one  or  more  will  be  looped  off.  These  may,  for 
greater  certainty  of  diagnosis,  be  put  under  the  microscope.  In  some 
cases  a  mamilloid  process  of  mucous  membrane  will  be  found  covered  over 
with  epithelium,  placed  edgewise  upon  it  with  great  regularity  ;  in  others, 
a  piece  of  placenta  will  be  seen  ;  while  in  a  few  cases  the  tale  will  be  told  of 
commencing  cancer  or  sarcoma,  which  will  yield  to  no  treatment  whatever. 

It  has  been  said  that  the  curette  gently  passed  over  the  endometrial 
surface  will  reveal  little  irregularities,  even  if  it  do  not  remove  them ; 
and  in  very  marked  cases  this  is  true,  but  he  who  relies  upon  this  as  a 
crucial  test  will  pass  over  many  minor  cases  requiring  diagnosis  and  treat- 
ment scarcely  less  than  they.  The  wire  hook  should  be  regarded  as  a 
valuable  diagnostic  resource  in  all  endometrial  outgrowths.  Employed 
as  such,  as  freely  as  I  make  use  of  it,  I  have  yet  to  see  an  accident  follow 
its  introduction  if  applied  with  caution.  I  have  seen  the  uterine  sound 
excite  peritonitis,  but  never  the  wire  loop  used  gently  for  the  purpose 
merely  of  diagnosis.  By  its  instrumentality  the  powerful  aid  of  the 
microscope  is  put  at  our  service,  and  many  an  obscure  case  will  be  made 
clear,  many  a  doubtful  one  set  at  rest  by  the  combination. 

Course,  Duration,  and  Termination These  growths  may  last,  produ- 
cing their  evil  results  for  years  ;  not  increasing  at  all,  but  not  diminishing. 
If  the  patient  become  pregnant,  the  changes  of  parturition  seem  in  some 
cases  to  destroy  their  activity,  but  even  this  they  at  times  resist,  and  after 
delivery  the  case  goes  on  as  before. 

Sometimes  the  little  growths  will  be  cast  off  and  appear  in  the  menstrual 
discharge.  But  this  casting  out  does  not  go  on  to  cure.  If  not  interfered 
with,  they  will  commonly  annoy  and  weaken  the  patient  until  the  meno- 
pause, when,  notwithstanding  their  presence,  the  uterine  flow  will  usually 
cease.  I  say  usually,  for  the  reason  that  in  some  cases  it  will  obstinately 
continue  at  irregular  intervals  for  years  after  its  occurrence. 


PROGNOSIS.  849 

The  remedy  to  which  I  have  made  allusion  as  having  been  introduced 
by  Recamier,  is  the  use  of  the  curette,  which  meets  the  requirements  of 
the  condition  perfectly.  It  must  not,  however,  be  supposed  that  one,  or 
even  several  applications  of  the  curette,  will  uniformly  cure  these  cases ; 
many  of  them  will  prove  very  obstinate,  rebellious,  and  perplexing.  Some 
years  ago,  I  attended,  with  Dr.  Fessenden,  of  Brooklyn,  a  young  lady 
of  sixteen,  who,  ever  'since  the  establishment  of  menstruation,  had  lost 
blood  so  freely  at  her  periods  as  to  be  alarmingly  exsanguinated.  I  em- 
ployed the  wire  curette,  and  removed  a  great  number  of  large  growths, 
and  she  got  up  apparently  well.  In  three  months,  however,  her  dangerous 
symptoms  returned,  and  the  operation  was  repeated  and  followed  by  in- 
jection of  compound  tincture  of  iodine  into  the  uterine  cavity.  Again  she 
got  better,  and  again  had  a  relapse  after  a  few  months.  Sims's  cutting 
curette  was  then  employed,  and  after  its  use  nitric  acid  was  applied  by 
Lombe  Athill's  method.  After  this  Dr.  Fessenden  occasionally  made  an 
application  of  iodine  to  the  uterine  cavity,  and  she  ultimately  recovered. 

In  another  case  which  I  attended  with  Dr.  L.  M.  Yale,  of  New  York, 
the  curette  was,  during  the  course  of  three  years,  used  ten  times,  very 
large  quantities  of  fungous  growths  being  each  time  removed;  and  the 
application  of  the  instrument,  Sims's  being  sometimes  employed,  and  at 
other  times  mine,  followed  by  free  applications  of  iodine  or  nitric  acid. 
After  a  time  we  felt  sure  that  sarcoma  or  cancer  must  be  the  basis  of  the 
affection,  but  Dr.  Delafield  cheered  us  with  the  assurance  that  this  was 
not  so,  and  the  justice  of  his  statements  was  verified  by  the  entire  recovery 
of  our  patient.  In  a  great  many  cases  I  have  had  to  repeat  the  operation 
of  scraping  about  once  a  year  for  a  long  time,  so  that  now  I  always  guard 
my  patients  against  this  possibility  for  fear  of  their  being  disappointed  at 
the  result. 

Another  curious  fact  connected  with  this  operation,  which  I  am  at  a 
loss  to  account  for,  is  the  irregularity  in  menstruation  which  occasionally 
follows  it.  The  period  next  succeeding  the  operation  will  possibly  be  as 
profuse  as  those  before  it,  but  after  this  the  patient  may  menstruate  very 
irregularly. 

Results Directly : — 

Menorrhagia ; 

Metrorrhagia ; 

Leucorrhoea. 
Indirectly : — 

Spanasmia ; 

Sterility; 

Constitutional  feebleness. 

Prognosis — This  will  depend  in  great  degree  upon  the  treatment 
adopted.     If  the  practitioner  be  one  of  those  who  abhor  a  resort  to  even 


350 


UTERINE    FUNGOSITIES, 


the  simplest  surgical  procedures,  and  who  rely  upon  constitutional  treat- 
ment in  all  these  affections,  the  prospects  of  the  patient  for  recovery  are 
poor.  If,  on  the  other  hand,  the  procedure  ahout  to  he  described  here  be 
resorted  to,  recovery  is  as  certain  as  the  method  is  simple  and  safe. 

Treatment — Recamier  advised  the  introduction  into  the  uterus  of  a 
small  scoop  called  the  curette,  by  which  these  growths  could  be  gently 
scraped  off'.  His  advice,  although  followed  by  some  able  men,  was  not 
generally  accepted,  and  his  method  excited  a  great  deal  of  hostility  which 
even  now  has  not  passed  away.  The  reason  for  this  was,  I  think,  the  fact 
that  the  instrument  employed  for  the  procedure  was  so  rough  and  harsh. 
At  a  later  period  Sims  introduced  the  steel  curette  shown  in  Fig.  128.  This 
was  an  advance  over  Recamier's  method  in  the  superiority  of  the  means 
for  attaining  the  end.  But  even  the  use  of  Sims's  cutting  steel  instrument 
was  too  dangerous,  and  the  operation  remained  imperfect.  For  a  number 
of  years  I  have  employed  the  instrument  shown  in  Fig.  129. 


Fig.  127. 


Fig.  128. 


Fig.  129. 


Rtcamier's  curette. 


Sims's  steel  rnrerte. 


Thomas's  wire  curette. 


It  consists  of  a  copper  wire  with  a  small  loop  at  its  extremity.  The 
loop  is  slightly  flattened  at  its  edges,  but  still  it  is  not  a  cutting  instru- 
ment. Even  if  applied  with  force,  it  can  do  no  serious  damage.  It 
removes  the  growths  by  looping  them  off,  not  by  cutting  or  tearing  the 
endometrium.  I  employ  it  very  largely  in  practice,  and  never  yet  have  I 
had  any  accident  follow  its  use  in  several   hundred  cases.     Of  course,  as 


DANGERS    OF    THE    CURETTE. 


351 


there  are  instances  in  which  the  passage  of  a  uterine  sound  will  cause 
peritonitis,  so  there  are  those  in  which  this  operation  may  end  fatally,  hut 
I  have  never  met  with  one,  and  no  one  could  use  it  more  freely  than  I  do. 

In  a  very  few  rare  cases  in  which  the  wire  curette  fails  to  effect  a  cure, 
I  employ  Sims's  more  powerful  instrument,  but  never  do  I  do  this  without 
good  reason. 

After  the  operation  the  patient  should  be  kept  perfectly  quiet  in  bed 
for  three  or  four  days,  and  any  tendency  to  inflammation  at  once  met 
by  the  treatment  appropriate  to  peritonitis. 

Dangers  of  the  Curette — The  dangers  which  attend  upon  the  use  of  the 
curette  are  : — 

Peritonitis. 

Cellulitis. 

Atresia  of  the  cervical  canal. 

Hemorrhage  some  hours  after  operation. 

I  have  seen  the  first  follow  the  use  of  the  steel  curette,  never  of  the 
wire.  It  should  be  guarded  against  by  care  after  operation,  perfect  rest 
for  several  days,  and  the  free  use  of  opium  in  case  of  pain.  The  second 
is  likely  to  occur  in  cases  in  which  cellulitis  has  existed  in  chronic  form 
before  resort  to  the  curette.  The  third  I  have  seen  in  one  case  after  the 
whole  corporeal  and  cervical  lining  was  thoroughly  scraped  by  the  cutting 
curette.  The  fourth,  which  I  have  once  met  with,  may  readily  be  pre- 
vented by  the  use  of  a  vaginal  tampon. 


Fig.  130. 


Emmet's  curette  forceps. 


Emmet,  in  the  hope  of  avoiding  these  dangers,  recommends  in  place  of 
the  curette,  the  use  of  a  pair  of  forceps  with  cutting  edges  shown  in 
Fig.  130. 

By  these  the  fungoid  growths  are  seized  and  removed  by  alternate  sepa- 
ration and  approximation  of  their  blades. 


dOZ         LACERATION  OF  THE  CERVIX  UTERI. 


CHAPTER   XXIV. 

LACERATION  OF  THE  CERVIX  UTERI. 

Definition — This  consists  in  the  tearing  of  the  wall  of  the  cervix  uteri 
during  labor  either  partly  or  entirely  through  the  tissue  which  com- 
poses it. 

History. — It  has  long  been  known  that  during  the  last  part  of  the  first 
stage  of  labor,  as  the  presenting  part  of  the  child  escapes  from  the  uterus 
and  enters  the  vagina,  the  circular  fibres  of  the  os  externum  and  of  the 
vaginal  portion  of  the  cervix  not  infrequently  give  way  under  the  exces- 
sive distention  which  occurs,  and  lacerations  in  one,  two,  or  more  direc- 
tions take  place.  In  1851  Sir  James  Simpson1  drew  attention  very  fully 
to  this  subject,  pointing  out  the  facts  that  lacerations  of  the  cervix  uteri 
are  of  very  frequent  occurrence,  that  they  are  not  the  result  of  misman- 
agement, that  they  are  so  common  after  first  labors  as  to  be  regarded  as 
reliable  signs  of  labor  having  occurred,  and  that  they  may  be  complete  or 
may  involve  only  the  mucous  and  middle  coats  of  the  cervix. 

Some  of  the  evil  results  of  the  condition  too  were  recognized,  as  will  be 
seen  by  reference  to  Dr.  Gardner's  work  upon  sterility,  where  it  is  credited 
with  the  causation  of  hypertrophy  of  the  cervix,  ulceration,  cervical  catarrh, 
sterility,  and  abortion. 

But  the  important  pathological  bearings  of  this  accident  upon  disorders 
of  the  uterus,  has  been  appreciated  only  of  late  years.  The  credit  of 
having  recognized  the  significance  of  the  lesion,  and  of  having  furnished 
us  with  a  safe  and  efficient  means  of  cure,  belongs  to  Dr.  T.  A.  Emmet. 
The  future  of  his  operation  for  its  relief  will  unquestionably  be  a  long  and 
brilliant  one,  and  its  results  will  effect  a  great  deal  of  good  for  uterine 
pathology.  Dr.  Emmet,  after  having  performed  the  operation  for  seven 
years,  published  his  first  paper  upon  it  in  18G9.  It  was  not,  however, 
until  a  second  paper  by  him  in  1874  that  the  importance  of  his  discovery 
was  fully  appreciated.  Since  that  period  it  has  gradually  risen  in  favor, 
although  even  now  its  great  merits  are  not  generally  recognized.  It  is 
surely  not  too  much  to  say  of  it  that  it  constitutes  one  of  the  most  import- 
ant contributions  to  gynecology  which  has  ever  been  made. 

Frequency No  reliable  statistics  are  at  our  disposal  upon  this  subject, 

for  the  reason  that  lacerations  of  the  cervix  exist  under  two  forms  with 

■  Edinburgh  Journ.  of  Med.  Science,  p.  488,  and  works  of  Sir  J.  Simpson,  Am. 
ed.  p.  152. 


PATHOLOGY.  353 

reference  to  pathology  :  first,  they  may  he  important  factors  ;  and  second, 
their  existence  is  recognized  hy  inspection,  but  they  produce  no  evil  re- 
sults whatsoever.  The  question  is  not  therefore  merely  how  often  the  cer- 
vix is  to  a  greater  or  less  degree  lacerated  during  parturition,  but  how 
often  such  laceration  is  productive  of  results  which  have  an  important  bear- 
ing on  uterine  pathology.  Simpson1  declared  that  evidence  of  a  certain 
degree  of  laceration  is  given  by  "  almost  every  careful  autopsy  of  women 
after  delivery,  whether  assisted  or  not  assisted  during  their  labor."  Em- 
met2 says,  "  at  least  one  half  of  the  ailments  among  those  who  have  borne 
children  are  to  be  attributed  to  lacerations  of  the  cervix."  Goodell3  esti- 
mates "  that  about  one  out  of  every  six  women  suffering  from  uterine 
trouble  has  an  ununited  laceration  of  the  cervix."  It  may  be  taken  for 
granted,  first,  that  a  certain  degree  of  laceration  of  the  vaginal  extremity 
of  the  cervix  uteri  is  the  rule  in  first  labors  ;  second,  that  a  certain  number 
of  these  are  entirely  recovered  from  or  exist  with  cicatrized  surfaces  with- 
out producing  pathological  consequences;  and  third,  that  in  a  large  pro- 
portion they  prove  important  factors  of  uterine  disease. 

The  great  reason  for  the  varying  results  of  laceration  is  this  :  if  it  inter- 
fere with  involution  of  the  body  or  cervix  of  the  uterus,  hyperplasia  either 
local  or  general  will  result,  with  accompanying  cystic  degeneration,  catar- 
rhal inflammation,  eversion,  and  congestion  ;  if,  in  spite  of  it,  involution 
goes  on  to  a  successful  issue,  the  parts  give  evidence  of  the  accident  only 
by  physical  examination,  not  by  pathological  results.  Upon  the  recogni- 
tion of  this  fact  should  rest  the  necessity  for  operative  interference.  If  it 
become  the  rule  of  practice  that  all  cervical  lacerations  should  be  closed 
without  reference  to  their  pathological  influences,  many  women  will  be 
exposed  to  operation  without  cause  and  without  compensation. 

Synonyms Lesser  degrees  of  laceration  are  described  as  fissures,  and 

cases  attended  by  eversion  of  the  cervical  endometrium  as  ectropion. 

Varieties — Laceration  may  be  partial,  where  the  mucous  or  middle 
coats  of  the  cervix  are  torn  through,  the  external  being  intact ;  and  com- 
plete where  the  whole  texture  of  the  canal  is  involved  in  the  rupture.  It 
may  likewise  be  bilateral,  unilateral,  or  stellate. 

Anatomy — It  must  be  remembered  that  this  accident  involves  the  lining 
membrane  of  the  cervical  canal,  with  its  reticulated  mucous  membrane  and 
immense  number  of  Nabothian  glands.  Should  it  produce  pathological 
results,  they  will  primarily  affect  these  parts,  secondarily  those  which  are 
more  remote. 

Pathology — Laceration  of  the  cervix,  occurring  as  it  does  during  partu- 
rition, is  very  apt  to  interfere  with  involution  of  the  cervix,  of  the  body,  or 
of  the  whole  uterus.     This  interference  may  be  very  slight  or  very  marked, 

1  Op.  cit.,  p.  152.  2  Op.  cit.,  p.  480. 

3  Lesson  in  Gynecology,  p.  169. 
23 


354         LACERATION  OF  THE  CERVIX  UTERI. 

the  degree  generally  depending  upon  the  extent  of  the  injury  inflicted. 
As  a  result  of  the  accident,  the  cervix  or  whole  uterus  remains  enlarged ; 
cystic  hyperplasia  affects  the  cervical  endometrium,  rich  in  glands;  hyper- 
secretion at  once  takes  place  very  markedly  ;  and  granular  degeneration 
with  eversion  of  the  lining  memhrane  occurs.  This  combination  makes 
up  the  condition  formerly  characterized  as  inflammatory  ulceration  of  the 
cervix  and  treated  by  depletion  and  caustics. 

I  would  not  be  understood  as  maintaining  that  unless  laceration  of  the 
cervix  produces  subinvolution  it  therefore  does  no  harm,  but  merely  as 
asserting  that  it  usually  and  chiefly  effects  its  results  in  that  manner. 
This  is  the  explanation  of  the  fact  that  section  of  the  non-parous  cervix 
for  removal  of  tumors  or  for  the  cure  of  sterility  or  dysmenorrhea  very 
rarely  results  in  any  of  the  evils  ordinarily  attendant  upon  laceration,  such 
as  eversion,  endometritis,  or  areolar  or  cystic  hyperplasia.  It  is  not  to  be 
denied,  however,  that  laceration  of  the  parous  uterine  neck,  unattended 
by  subinvolution,  and  section  of  the  non-parous,  sometimes,  by  slight  ever- 
sion of  the  mucous  membrane  and  the  influence  of  friction  from  the  vagi- 
nal walls,  eventuate  in  areolar  or  cystic  hyperplasia  with  endometritis  and 
granular  degeneration.  The  last  is  not  a  necessary  result  of  laceration, 
but  is  produced  indirectly  by  the  ichorous  mucus  which  is  secreted  by  the 
inflamed  endometrium. 

Causes Every  patient,  when  informed  as  to  the  existence  and  origin 

of  this  condition,  instinctively  turns  in  a  direction  to  which  the  mind  of 
woman  has  a  natural  proclivity,  that  of  censuring  the  medical  attendant 
for  the  unfortunate  result.  It  becomes  the  bounden  duty,  at  the  present 
day,  for  the  gynecologist  to  remove  fully  and  completely  all  such  disposi- 
tion on  the  part  of  the  patient,  not  as  a  matter  of  professional  courtesy, 
but  of  simple  justice.  Let  a  patient  be  ever  so  well  attended,  this  acci- 
dent may,  as  Prof.  Simpson  pointed  out,  occur  even  after  a  short  and 
natural  delivery.  It  will  be  noticed  that  I  say  that,  "at  the  present  day," 
no  blame  should  be  allowed  to  attach  to  the  attending  obstetrician.  I 
feel  sure  that  this  will  not  be  so  in  the  future.  It  is  true  that  even  then 
prevention  will  prove  impossible ;  but  not  so,  early  recognition.  Six 
weeks  or  two  months  after  delivery  every  parturient  woman  should,  with 
our  present  lights,  be  examined  as  to  the  condition  of  the  perineum  and 
cervix  uteri.  It  is  an  entirely  fallacious  position  to  assume  that  an  ex- 
amination just  after  labor  reveals  the  real  state  of  these  parts.  No  one 
could  then  thoroughly  inform  himself,  except  by  an  exploration  the  ex- 
posure attendant  upon  which  would  defeat  its  practice.  As  far  as  the 
cervical  injury  is  concerned,  too,  even  if  discovered  just  after  labor,  it 
could  not  then  be  operated  on,  and  by  the  end  of  the  r.eriod  of  involution 
it  might  have  entirely  disappeared.  An  examination  at  the  time  when  a 
parturient  woman  should  be  discharged  from  the  obstetrician's  observation, 
the  end  of  the  period  of  involution,  and  not  the  ninth  day,  as  is  now  gene- 


PHYSICAL    SIGNS.  355 

rally  done,  would  reveal  the  true  condition  of  things,  and  in  a  great  many 
cases  avoid  tor  women  lives  of  suffering  and  invalidism.  A  laceration  of 
the  cervix  being  discovered,  it  would  not  follow  that  operation  would  be 
inevitable,  but  the  obstetrician,  being  now  forewarned,  would  be  prepared 
to  act  for  the  best  interests  of  his  patient. 

The  chief  causes  of  laceration  of  the  cervix  may  thus  be  stated  : — 

Precipitate  labor ; 

Manual  delivery  ; 

Instrumental  delivery ; 

Labor  with  rigidity  of  os  ; 

Cicatricial  material  in  tissue  of  cervix ; 

Cancerous  degeneration  of  cervix  ; 

Section  of  cervix  during  labor  ; 

Too  early  evacuation  of  the  liquor  amnii ; 

Abortion. 
In  my  own  experience  I  have  met  with  every  cause  here  stated  as  pro- 
ductive of  this  accident,  the  first  three  recorded  being  infinitely  the  most 
frequent.  Head  last  labors,  calling  as  they  do  for  the  very  rapid  passage 
through  a  badly  dilated  os  of  an  uncompressed  head,  often  induce  it,  but 
these  I  consider  in  the  category  of  "  manual  delivery."  Emmet  considers 
criminal  abortion  a  particularly  frequent  cause,  though  it  is  difficult  to 
see  why  it  should  be  more  so  than  that  from  accidental  causes. 

Symptoms — The  rational  signs  of  this  condition  are,  as  a  rule,  nume- 
rous and  important : — 

Pain  in  back  and  loins  ; 

Sense  of  "  bearing  down  ;" 

Leucorrhoea ; 

Increase  or  diminution  in  menstruation ; 

Sometimes  hemorrhage  after  coition  ; 

Neuralgia  of  cervix ; 

Sometimes  sterility ; 

Discomfort  in  locomotion  ; 

Dyspareunia. 
All  these,  of  course,  do  not  occur  in  any  one  case.     Some  cases  present 
some  of  them,  and  some  others. 

Physical  Signs The   examination  for   this   lesion   should  always  be 

made  with  Sims's  speculum  or  one  of  its  modifications.  By  the  cylin- 
drical speculum,  or  by  those  valvular  ones  which  distend  the  vagina 
slightly,  it  is  often  not  recognizable,  and  always  imperfectly  appreciated. 
This  furnishes  a  good  illustration  of  the  truth  of  the  position  elsewhere 
assumed  in  this  work,  that  the  gynecologist  who  habitually  employs  Sims's 
method  of  examination  stands  upon  a  vantage  ground  unattainable  by  one 
who  does  not  do  so. 

The  cervix,  being  exposed  to  view,  will  be  seen  to  present  somewhat 
the  appearance  shown  in  Figs.  131  and  132. 


356         LACERATION  OF  THE  CERVIX  UTERI. 

Fig.  131. 


Bilateral  laceration  to  vaginal  junction.    A,  A,  lips  of  the  severed  os  externum. 
B,  os  internum. 

Fig.  132. 


Bilateral  laceration  to  vaginal  junction, -with  hyperplasia  of  cervical  walls.    A,  A,  lips  of  severed 
os  externum.     B,  os  internum. 


PHYSICAL    SIGNS. 


357 


In  both  these  diagrams  the  round  spots  on  the  cervical  walls  represent 
enlarged  Nabothian  follicles;  in  the  second  the  dotted  lines  must  receive 
no  attention,  as  they  refer  to  something  to  come  hereafter.  But  these 
diagrams,  although  conveying  correct  ideas  of  the  general  nature  of  cervi- 
cal lacerations,  do  not  sufficiently  portray  the  many  variations  which  this 
interesting  and  important  lesion  may  assume.     Fig.  133  represents  the 

Fig.  133. 


Double  tenaculum  separating  the  flaps  of  a  [unilateral]  laceration.     (Emmet.) 


more  detailed  outline  of  a  unilateral  laceration,  the  rent  being  posterior, 
and  Fig.  134  of  a  multiple  or  stellate  rupture. 

Fig.  134. 


Multiple  or  stellate  laceration  of  the  cervix.     (Emmet.) 


Many  cases  of  the  varieties  of  cervical  laceration  which  I  have  men- 
tioned, unilateral,  bilateral,  and  multiple,  whether  these  be  complete  or 
partial,  are  obscured  by  hyperplasia  and  eversion  of  the   endometrium, 


358  LACERATION    OF    THE    CERVIX    UTERI. 

with  its  glands  in  a  condition  of  cystic  degeneration ;  by  areolar  hyper- 
plasia of  one  or  both  lips  of  the  tear ;  and  by  granular  degeneration  going 
on  to  development  of  extensive  exuberant  growths.  These  can  only  be 
recognized  by  careful  and  attentive  examination.  For  excellent  delinea- 
tions of  these  and  life-like  representations  of  them,  I  would  refer  the 
reader  to  some  colored  lithographs  by  Dr.  P.  F.  Munde.1 

The  parts  being  exposed  to  view  by  the  speculum,  a  tenaculum  should 
be  fixed  in  each  extremity  of  the  severed  cervix  and  its  divided  walls 
drawn  together.  As  they  come  into  contact,  the  normal  shape  of  this 
part  will  present  itself  to  view  and  at  once  be  recognized  unless,  as  in 
Fig.  134,  so  much  hypertrophy  has  occurred  on  the  inner  walls  of  the  two 
sides  as  to  render  this  impossible.  Even  then,  however,  an  approxima- 
tion to  the  truth  may  always  be  arrived  at. 

Differentiation The  conditions  from  which  laceration  of  the  cervix 

will  generally  have  to  be  differentiated  are  these : — 

Granular  degeneration ; 

Cystic  degeneration  ; 

Simple  hyperplasia  or  hypertrophy; 

Malignant  disease. 
It  will  often  prove  by  no  means  easy  to  arrive  at  certainty  until  the 
case  has  been   kept  for  some  time  under  observation.     From  cancerous 
exuberation  from  the  endometrium  the  microscope  will  sometimes  prove 
the  only  certain  method  of  differentiation. 

Results Nothing  more  triumphantly  displays  the  value  of  Emmet's 

contribution  to  gynecology  in  connection  with  cervical  lacerations  than  a 
full  exhibit  of  the  evils  which  result  from  that  condition.  Its  ordinary 
consequences  are — 

Chronic  peri-uterine  cellulitis  ; 

Epithelioma  ; 

Subinvolution  of  a  part  or  the  whole  of  the  uterus; 

Sterility; 

Menstrual  disorders ; 

Cervical  endometritis ; 

Granular  and  cystic  degeneration  ; 

Fungosities  of  corporeal  endometrium  ; 

Neuralgia  of  cervix ; 

Dyspareunia ; 

Tendency  to  abortion  ; 

Uterine  displacements. 
There  can  be,  on  the  part  of  those  who  have  been   properly  impressed 
with  the  importance  of  this  lesion,  no  question  as  to  the  truth  that  all  the 
conditions  mentioned  may  originate  from  this  accident. 

1  Am.  Journ.  Obstet.  and  Dis.  of  Women  and  Children,  Jan.  1879,  p.  134. 


TREATMENT.  359 

No  part  of  the  body  of  a  woman  is  so  liable  to  the  development  of 
cancer  as  the  uterus ;  no  part  of  the  uterus  so  liable  to  it  as  the  neck  ;  and 
no  tissue  of  the  neck  so  liable  to  it  as  the  glandular  lining  membrane. 
Exposure  of  this  by  eversion,  the  result  of  laceration,  would,  theoretically, 
be  supposed  to  be  a  fruitful  exciting  cause  of  that  affection,  and  practical 
observation  abundantly  supports  theory  in  reference  to  the  matter.  My 
own  observation  has  for  several  years  made  me  feel  sure  of  this,  and  that 
of  Breiskey,  Emmet,  and  Veit  is  recorded  to  the  same  effect.  This  alone 
offers  a  valid  indication  for  the  closure  of  lacerations  attended  by  local 
engorgements  and  irritation. 

Prognosis — As  time  passes,  the  raw  surfaces  of  the  lacerated  cervix 
may  gradually  become  cicatrized,  its  evil  results  diminish,  hyperplasia 
disappear,  and  the  patient  enjoy  very  good  health,  in  spite  of  the  fact  that 
the  condition  still  exists.  This  may  occur  without  treatment,  though  the 
application  of  alteratives,  escharotics,  and  astringents,  as  iodine,  nitrate 
of  silver,  cantharides,  tannin,  alum,  zinc,  etc.,  unquestionably  hastens  and 
secures  the  result.  Ordinarily  the  patient  remains  to  a  certain  extent  an 
invalid  until  the  menopause,  when  the  occurrence  of  atrophy  of  the  internal 
genitalia  effects  a  removal  of  the  consequences  of  the  laceration. 

Treatment — This  may  be  palliative  or  curative,  the  former  being  appro- 
priate to  cases  in  which  from  any  cause  the  operation  of  trachelorrhaphy 
cannot  be  performed.  Palliative  treatment  consists  in  the  use  of  copious 
hot  water  vaginal  injections,  evacuation  of  cervical  cysts  by  puncture, 
application  of  alteratives,  such  as  iodine,  nitrate  of  silver,  glycerole  of 
tannin,  removal  of  all  superincumbent  weight,  and  direct  support  of  the 
uterus  by  a  pessary. 

Curative  treatment  consists  in  repair  of  the  laceration  by  trachelor- 
rhaphy, after  the  patient's  general  condition  has  been  rendered  good  and 
the  affected  parts  have  been  properly  prepared  for  operation  by  the  pallia- 
tive course  just  mentioned. 

I  will  describe  the  operation  as  applied  to  a  case  of  bilateral  laceration. 
The  patient  being  anaesthetized  and  placed  upon  a  table  before  a  window, 
in  Sims's  position,  his  speculum  should  be  introduced,  and  two  tenacula 
fixed,  one  in  each  flap  of  the  laceration,  and  they  should  be  approximated. 
If  this  can  be  effected,  the  operator  determines  exactly  where  his  denuda- 
tion is  to  be  made ;  if  it  be  found  to  be  impossible,  he  recognizes  the  fact 
that  the  case  will  require  a  special  plan  of  treatment,  which  is  soon  to  be 
described.  Having  decided  where  the  denudation  is  to  be  made,  the 
operator  catches  the  lower  side  of  one  flap,  and,  by  scissors,  cuts  away 
the  mucous  membrane  and  a  small  portion  of  the  parenchyma  as  far  as 
the  angle  made  by  the  junction  of  the  two  flaps.  Then  seizing  the  other 
flap  he  treats  it  in  the  same  wTay,  the  strip  of  separated  tissue  being  now 
completely  removed.  The  same  process  is  gone  through  with  on  the  other 
side,  the  resultant  of  both  being  two  long  raw  surfaces,  one  on  each  side 


360 


LACERATTON  OF  THE  CERVIX  UTERI. 


of  the  laceration,  with  a  strip  of  undenuded  tissue  extending  upwards  to  or 
towards  the  os  internum.     Fig.  135  will  show  this. 


Fin.  135. 


Lacerated  cervix  denuded,  and  strip  of  undenuded  surface  left  to  act  as  a  cervical  canal. 

The  flow  of  blood  is  now  stanched,  if  necessary,  by  a  tampon  of  linen 
or  cotton  left  in  place  for  five  or  ten  minutes.  The  operator,  again  fixing 
the  tenacula,  ascertains  by  approximation  of  the  opposing  denudations  that 
they  will  after  passage  of  the  sutures  lie  in  contact  with  each  other,  and 
proceeds  to  the  second  step  of  the  operation. 

Fixing  the  tenaculum  in  the  cervix  near  the  upper  angle  of  the  lacera- 
tion, he  now  passes  through  one  flap  a  sharp-pointed,  short  needle,  held  in 
the  needle  forceps.  The  needle  is  introduced  about  a  quarter  of  an  inch 
from  the  edge  of  the  denudation,  passed  through,  and  in  the  same  way 
carried  through  the  opposite  lip.  This  needle  is  armed  with  a  loop  of 
silk  by  means  of  which  a  silver  wire  is  drawn  into  place,  the  ends  of 
which  are  placed  under  the  finger  of  the  person  holding  the  speculum. 
One  after  the  other  wire  sutures  are  passed  from  above  downwards,  about 
n  third  of  an  inch  apart,  until  the  lower  extremity  of  the  laceration  is 
reached.  Then  the  other  side  is  treated,  if  it  be  a  bilateral  laceration,  in 
the  same  manner. 

The  sutures  are  now  twisted  one  by  one,  the  upper  ones  being  first 
dealt  with,  until  all  are  twisted,  when  each  one  is  bent  downwards  so  as 


TREATMENT. 
Fig.  136. 


3G1 


Sutures  passed  after  denudation  of  cervix. 

to  lie  flat  against  the  wall  of  the  cervix.  The  conclusion  of  this  procedure 
is  shown  in  Fig.  137. 

In  case  the  laceration  is  multiple  or  stellate  like  that  shown  in  Fig. 
134,  it  is  not  proper  to  close  each  little  fissure  separately,  but  cutting  up 
on  each  side  to  the  vaginal  junction  so  as  to  make  the  laceration  one  of 
bilateral  variety,  denuding  still  more  so  as  to  narrow  the  cervical  canah 
and  then  closing  by  suture  as  already  described. 

Still  another  class  of  cases  must  be  mentioned.  Sometimes  hyperplasia 
of  the  inner  walls  of  the  cervix  has  occurred  to  such  an  extent  as  to  pre- 
vent easy  approximation  of  the  opposing  flaps,  as  shown  in  Fig.  132. 
Here  it  is  necessary  to  cut  away  the  hypertrophied  tissue  below  the  dotted 
lines,  and  then  the  cervical  walls  will  readily  come  into  apposition. 

The  patient,  after  the  operation,  should  be  confined  to  bed  and  kept 
upon  low  diet.     The  bowels  may    be  moved  every  day,  and   the  urine 


362         LACERATION  OF  THE  CERVIX  UTERI. 

evacuated  upon  the  bed-pan.  Twice  a  day  the  vagina  should  be  cleansed 
by  a  warm,  carbolized  injection,  and  on  the  eighth  or  ninth  day  the  sutures 
should  be  very  cautiously  removed  beginning  with  those  above.  If  union 
have  not  occurred  or  seem  very  weak,  the  lower  ones  may  be  left  for  a 
fortnight. 

Fig.  137. 


Sutures  twisted  and  bent  downwards  against  the  wall  of  the  cervix. 

The  operation  sometimes,  though  very  rarely,  results  in  cellulitis  or 
peritonitis,  and  considering  the  good  which  it  accomplishes  is  remarkably 
free  from  risk.  The  use  of  a  pessary  to  sustain  the  heavy  uterus  is  often 
advisable  for  two  or  three  months  after  recovery. 


DISPLACEMENTS    OF    THE    UTERUS.  303 


CHAPTER   XXV. 

GENERAL  CONSIDERATIONS  UPON  DISPLACEMENTS  OF  THE  UTERUS. 

History That   the  earliest   practitioners  of  medicine   were    familiar 

with  this  subject  is  abundantly  attested  by  the  writings  of  the  Greek  and 
Roman  schools.  It  is  distinctly  mentioned  by  Hippocrates,  and  more 
clearly  and  exactly  still  by  Galen  and  Moschion  about  the  second  century 
of  the  Christian  era.  This  remark  applies  not  only  to  prolapse,  but  also 
to  versions,  which  were  evidently  understood.  Hippocrates  and  Moschion 
even  described  latero-version,  a  variety  which  has  not  been  much  noticed 
by  modern  writers,  and  Aetius1  in  the  sixth  century  indicates  the  method 
for  reduction  and  retention  in  place  of  the  retroverted  womb.  Although 
certain  passages  in  the  works  of  these  old  writers  seem  obscurely  to  refer 
to  bending  of  the  uterus  upon  itself,  such  for  example  as  one  in  which 
Hippocrates  speaks  of  cases  in  which  "  uterorum  os  conclusum,  aut  con- 
tor •turn  ftier it ,"  there  is  no  satisfactory  evidence  that  they  understood  the 
difference  between  versions  and  flexions. 

Passinor  over  many  centuries,  at  the  middle  of  the  eighteenth  we  find 
gynecologists  paying  attention  to  versions,  and  even  to  flexions,  of  the 
pregnant  uterus,  but  losing  sight  of  these  displacements  in  the  non-preg- 
nant organ.  Versions  were  at  that  period  described  by  Gartshore,  W. 
Hunter,  Jahn,  and  Desgranges ;  and  flexions  by  Saxtorph,  Wltczek, 
Baudelocque,  and  Boer.  Gartshore  describes  a  case  of  retroflexion  com- 
plicated by  retroversion,  but  the  flexion  appears  to  have  made  little  im- 
pression upon  him.  In  1775  Saxtorph  wrote  an  essay  entitled  "De  Is- 
churia ex  utero  retroflexo,"  describing  a  case  with  autopsy,  but  the  words 
"  orificium  alte  supra  pubem  reperi,"  show  that  it  was  not  a  true  case. 
About  the  same  time  Wltczek  published  an  unquestionable  case  "  de  utero 
retroflexo,"  but  it  occurred  during  utero-gestation,  and  hence  does  not 
concern  our  inquiry.  Both  in  England  and  France  the  subject  of  dis- 
placements attracted  great  attention  at  this  period.  "  At  this  time  Cho- 
part  upon  his  return  from  England,  where  he  became  well  acquainted 
with  W.  Hunter,  informed  the  Academy  of  Surgery  what  progress  was 
beino-  made  in  a  subject  which  had  attracted  attention  in  France  thirty 
years  before."2 

1  Tetrabiblos,  ch.  lxxvii. 

2  Cusco,  "These  de  1' Anteflexion  et  de  la  Retroflexion  de  l'Uterus,"  Paris, 
1853. 


364  DISPLACEMENTS    OF    THE    UTERUS. 

Denman  was  the  first  writer  who  described  flexion  of  the  non-pregnant 
uterus,  which  he  did  in  reference  to  a  case  of  retroflexion,  about  the  year 
1800.  The  wanting  link,  the  description  of  anterior  flexure,  was  not 
supplied  until  M.  Ameline,  of  France,  described  anteflexions  in  1827. 
After  this  many  others  added  to  the  knowledge  of  the  subject,  which  soon 
assumed  its  place  in  systematic  medical  literature.  A  great  deal  was 
done  for  it  by  the  introduction  of  the  uterine  sound  as  a  means  of  diagnosis 
and  of  reposition. 

In  carefully  perusing  more  modern  literature  with  reference  to  its  con- 
tributions to  uterine  flexions,  I  am  impressed  with  the  belief  that  we  are 
indebted  to  none  more  fully  than  to  Cusco,  whose  very  valuable  thesis  I 
have  alluded  to,  and  Graily  Hewitt,  whose  views  are  familiar  to  all. 

In  this  country  the  profession  is  generally  indebted  for  correct  views 
upon  the  subject  to  Dewees,  Meigs,  and  Hodge.  More  especially  has  the 
last  of  these  identified  his  name  with  it  by  important  contributions  to 
pathology  and  treatment. 

Pathological  Significance  of   Versions  and  Flexions The  ancients 

ascribed  to  these  displacements  many  constitutional  evils,  as  paralysis, 
hysteria,  etc.,  and  even  until  a  very  recent  period  they  were  credited  with 
a  great  deal  of  pelvic  pain  and  functional  uterine  disturbance,  which  it  was 
supposed  almost  universally  attended  them.  Until  1854  this  belief  pre- 
vailed very  generally,  having  the  powerful  support  and  endorsement  of 
such  men  as  Velpeau,  Simpson,  and  Valleix.  It  is  true  that  it  was  con- 
tested by  Cruveilhier  and  Dubois,1  before  the  period  mentioned ;  but  at 
that  time  a  spirited  discussion  arose  concerning  it  in  the  Academy  of 
Medicine  of  Paris,  which  not  only  threw  much  doubt  upon  it,  but  gave 
rise  to  a  powerful  opposition,  in  the  ranks  of  which  appeared  Depaul,  H. 
Bennet,  Aran,  Becquerel,  and  others  equally  eminent.  They  maintained 
that  these  displacements  of  the  womb,  if  unaccompanied  by  textural 
lesion,  produced  no  constitutional  disturbance  ;  created,  as  a  rule,  no  dis- 
comfort ;  and  did  not  deserve  the  attention  in  treatment  which  had  been 
bestowed  upon  them.  They  did  not  believe  that  the  dislocation  was  the 
cause  of  suffering  when  this  existed  alone,  but  looked  upon  it,  in  such 
cases,  as  an  epiphenomenon  engrafted  upon  some  important  lesion.  Con- 
sequently they  were  opposed  to  reliance  being  placed  upon  support  by 
pessaries  as  one  of  the  essentials  of  treatment,  as  had  been  done  by  the 
other  school. 

When  views  supposed  to  be  false  are  repudiated,  those  adopting  new 
ones  are  always  apt  to  run  too  far  into  an  opposite  extreme,  and  in  this 
instance  many  have  done  so.  Scanzoni2  sounds  the  keynote  of  this  extreme 
party  when  he  states,  that  "  flexions  of  the  womb  do  not  acquire  any  impor- 

i  Goupil,  B.  &  G.,  op.  cit.,  p.  459.  8  Op.  cit.,  Amer.  ed.,  p.  112. 


VERSIONS    AND    FLEXIONS.  365 

tance,  nor  are  followed  by  any  serious  dangers,  save  when  they  are  com- 
plicated with  an  alteration  in  the  texture  of  the  organ." 

The  following  propositions  present  the  views  upon  this  subject  which  I 
think  will  be  found  to  bear  the  test  of  experience  : — 

1st.  Versions  and  flexions  of  the  womb  may,  but  very  rarely  do,  exist 
without  causing  any  symptoms,  for  in  themselves  they  do  not  constitute 
disease.  Thus  it  is  that  in  rare  cases  we  see  the  uterus  forced  completely 
out  of  its  place,  without  the  production  of  morbid  signs. 

2d.  By  interfering  with  escape  of  menstrual  blood,  by  disordering  ute- 
rine circulation,  and  keeping  up  hyperemia,  by  causing  pressure  and 
friction  from  contact  with  surrounding  parts,  and  by  creating  a  barrier  to 
the  entrance  of  seminal  fluid,  they  become,  as  a  general  rule,  of  great 
importance  and  require  special  attention. 

3d.  Often  being  the  results,  as  they  are  sometimes  the  causes,  of  uterine 
and  periuterine  diseases,  their  treatment  should  be  combined  with  efforts 
at  the  alleviation  of  these  states. 

4th.  Treatment  by  pessaries,  combined  with  means  which  remove  the 
weight  of  the  superincumbent  intestines,  is  of  great  value.  By  it,  even 
although  the  primary  disease  is  not  affected,  we  may  relieve  one  of  its 
most  troublesome  symptoms,  which  often  reacts  for  evil  in  aggravating 
and  prolonging  the  affection  which  caused  it.  When  the  displacement 
has  resulted  from  relaxation  of  the  uterine  ligaments,  in  consequence  of 
increased  weight  or  pressure  from  the  abdominal  viscera,  pessaries  prove 
a  most  useful  and  efficient  means  of  treatment. 

oth.  One  reason  for  the  great  prejudice  existing  against  the  use  of 
pessaries  in  the  minds  of  many  is  to  be  found  in  the  fact  that  most  of  the 
enlargements  of  the  uterus  were  attributed  unhesitatingly  to  parenchyma- 
tous inflammation.  Mechanically  lifting  an  inflamed  organ  appeared 
repulsive  to  reason.  So  long  as  the  existing  inflammation  was  uncured, 
efforts  appeared  to  be  directed  to  a  side  issue,  a  result  and  not  the  root  of 
the  disorder.  Since  it  is  now  known  that  what  was  supposed  to  be  chronic 
metritis  is  really  a  vice  of  nutrition  resulting  in  new  formation  of  connec- 
tive tissue,  this  theoretical  objection  falls  to  the  ground. 

Gth.  Another  reason  is  this :  it  requires  skill,  and  ingenuity,  the  result 
of  practice,  not  only  to  do  good  with  pessaries,  but  to  apply  them  without 
doing  absolute  harm.  In  the  hands  of  a  physician  who  has  made  no 
special,  or  atdeast  careful,  study  of  their  use,  and  who  habitually  applies 
only  a  half-dozen  in  the  course  of  every  year,  pessaries  are  elements  of 
absolute  danger.  It  would  be  as  unreasonable  to  expect  an  untaught 
experimenter  to  fit  the  foot  comfortably  with  a  shoe,  as  to  hope  for  effi- 
ciency, comfort,  and  safety  from  a  pessary  applied  by  ignorant  hands. 

7th.  The  gynecologist  who  to-day  assumes  the  position  that  pessaries 
are  useless  or  worse,  and  treats  uterine  displacements  without  their  aid, 


366  DISPLACEMENTS    OF    THE    UTERUS. 

will  fail,  by  reason  of  the  absence  of  other  means  to  accomplish  the  existing 
indications,  to  meet  the  requirements  of  his  cases. 

Definition  and  Synonyms The  term  displacement  is  applied  by  British 

and  American  writers  to  any  decided  removal  of  the  uterus  from  its  normal 
position,  without  reference  to  the  direction  in  which  it  has  been  moved ; 
while  French  writers  apply  the  term  displacement  only  to  ascent  and 
descent  of  the  uterus,  reserving  that  of  deviations  for  versions  and  flexions. 

Anatomy. — One  of  the  salient  points  in  the  comprehension  of  this  most 
important  subject  consists  in  a  clear  understanding  of  the  natural  position 
of  the  healthy  uterus.  But  unfortunately,  owing  to  the  fact  that  the 
position  of  this  organ  varies  constantly  with  inspiration  and  expiration, 
with  muscular  effort  and  quietude,  and  with  fulness  and  emptiness  of  the 
bladder  and  rectum,  it  is  difficult  to  arrive  at  common  ground  with  refer- 
ence to  a  point  apparently  so  easy  of  settlement.  As  this  chapter  pro- 
gresses, I  propose  to  put  before  the  reader  a  diagram  of  the  normal  posi- 
tion of  the  uterus  when  not  influenced  by  any  decided  disturbing  cause. 
It  is  the  result  of  long  and  careful  investigation,  and  represents  the  truth, 
I  think,  more  accurately  than  any  other  with  which  I  am  acquainted. 

Let  any  one  examine  a  healthy  uterus  by  means  of  Sims's  speculum, 
and  he  will  recognize  that  it  is  delicately  and  perfectly  poised  near  the 
middle  of  the  pelvic  cavity  by  such  supporting  influences  that  it  is  never, 
even  for  a  few  seconds,  perfectly  at  rest.  It  ascends  with  expiration  and 
descends  with  inspiration  with  such  regularity  and  distinctness,  that  one 
operating  upon  the  pelvic  viscera  can,  by  this  up-and-down  movement, 
recognize  at  once  when  an  anaesthetic  is  affecting  respiration  badly.  Under 
the  influence  of  more  decided  factors,  such  as  pregnancy,  repletion  of  blad- 
der or  rectum,  or  violent  muscular  efforts,  still  more  marked  changes  of 
position  occur  to  it.  Nevertheless  we  must  agree  upon  a  medium  position 
as  the  normal  one  for  a  healthy  uterus. 

The  mechanical  influences  which  sustain  the  uterus  and  preserve  its 
pelvic  equipoise  are  five  in  number.     These  are — 

1st.  The  retentive  power  of  the  abdominal  cavity. 

2d.  The  attachments  to  the  areolar  tissue  of  the  pelvis. 

3d.  The  juxtaposition  of  the  other  organs. 

4th.  The  vaginal  promontory  upon  which  the  neck  rests. 

5th.   The  following  ligaments  : — 

a.  The  round  ligaments,  continuations  of  uterine  tissue,  extending  from 

uterine  horns  to  labia  majora; 

b.  The  utero-vesical -ligaments,  bands  of  pelvic  fascia,  and  uterine  muscular 

tissue  passing  between  the  bladder  and  the  cervico«corporeal  junc- 
tion, where  they  attach  themselves,  and  prevent  retreat  of  cervix  ; 

c.  The   utero-sacral    ligaments,   formed  of  hypogastric    fascia,  and    the 

uterine  and  vaginal  tissue,  extending  from  posterior  surface  of 
cervix,  passing  backwards  to  be  attached  to  sacrum,  and  prevent- 
ing passage  of  cervix  forwards; 


ANATOMY, 


807 


d.  The  broad  ligaments,  folds  of  peritoneum  inclosing  areolar  tissue, 
ovarian  and  round  ligaments,  and  ovaries ;  preventing  lateral, 
anterior,  and  posterior  displacements. 

None  of  these  means  of  suspension  are  concerned  in  flexions  and  inver- 
sion, which  are  combated  by  forces  of  entirely  different  nature.  The 
tissue  of  the  normal,  unimpregnated  uterus  is  of  such  strong,  resisting 
character  in  the  adult  female,  as  to  prevent  too  great  a  curvature  of  the 
body  upon  the  neck  either  anteriorly,  laterally,  or  posteriorly.  It  is  to 
this  peculiarity  of  structure  that  immunity  from  these  conditions  is  due. 

When  stimulated  by  pregnancy,  the  uterine  tissue  develops  rapidly  into 
muscular  structure.  This  keeps  the  cavity  of  the  organ  closed  by  tonic 
contraction,  and  removes  the  possibility  of  inversion  unless  it  be  accom- 
plished by  absolute  violence.  But  when  from  any  cause  this  contractile 
power  is  destroyed  and  the  condition  of  tone  is  replaced  by  one  of  atony, 
flexion  or  inversion  may  occur. 


Fig.  138. 


The  regions  of  the  abdomen  and  their  contents.    Edge  of  costal  cartilages  in  dotted  outlines. 

(Gray.) 

The  retentive  power  of  the  abdomen  is  one  of  the  most  important  influ- 
ences for  the  support  of  the  uterus,  and  one  of  the  most  neglected  in  con- 
sideration of  this  subject.     Fig.  138  represents  the  abdominal  viscera  in 


368 


DISPLACEMENTS    OF    THE    UTERUS. 


their  normal  condition  and  place.  The  diaphragm,  one  of  the  muscles 
most  essential  to  respiration,  is  located  nearly  midway  in  the  trunk,  across 
which  it  extends  like  a  concavo-convex  curtain.  "  Its  action  exactly  re- 
sembles that  of  a  piston  in  the  cylinder  of  a  pump."1  As  it  contracts  it 
forces  the  abdominal  viscera  downwards  directly  upon  those  of  the  pelvis, 
and  as  it  relaxes,  and  expiration  occurs,  the  depressed  abdominal  viscera 
rise  to  their  former  place,  drawing  the  pelvic  viscera  upwards.  This 
up-and-down  movement  not  only  keeps  the  uterus  in  place,  but  it  exerts 
a  powerful  stimulating  influence  upon  its  circulation,  and  prevents  that 
tendency  to  sluggishness  which  perfect  quietude  so  markedly  favors.  Dr. 
Matthews  Duncan2  has  very  ably  treated  of  this  important  subject,  and 
done  a  great  deal  of  good  with  reference  to  it ;  an  excellent  contribution 
has  been  made  to  it  by  Dr.  Busey,3  of  Washington ;  and  a  remarkable  work 
has  been  written  upon  it  in  its  various  aspects  by  Dr.  Geo.  H.  Taylor,4  of  New 

Fig.  139. 


Normal  position  of  the  uterus. 


York.  In  my  mind  its  importance  cannot  be  over  estimated,  for  I  believe 
that  more  valuable  contributions  to  the  etiology  of  uterine  displacements 
in  the  future  will  come  from  investigations  in  this  direction  than  any  other. 


1  Course  of  Lectures  on  Physiology,  by  Prof.  Kiiss,  of  University  of  Strasbourg, 
p.  294. 

2  Researches  in  Obstetrics. 

3  Amer.  Journ.  Obstet.,  February,  1872,  p.  585. 

4  Diseases  of  Women,  1871. 


ANATOMY.  3»)9 

Fig.  139  represents  the  results  of  my  researches  as  to  the  normal  posi- 
tion of  the  uterus,  the  bladder  and  rectum  not  being  entirely  empty.  1 
shall  allude  in  detail  here  to  only  one  other  factor  in  uterine  support. 
The  cervix  will  be  observed  to  impinge  slightly  upon  the  anterior  rectal 
wall,  and  to  depress  it  a  little.  This  a  rectal  examination  will  usually 
reveal  as  the  rule.  The  perineal  body  being  normal,  the  posterior  vaginal 
wall  will  from  this  point  be  found,  upon  careful  vaginal  touch,  to  rise  up 
below  the  cervix,  which  will  thus  rest  in  a  very  shallow  well  or  depression, 
the  anterior  cervical  wall  being  supported  as  if  by  a  shelf,  by  the  anterior 
projection  of  this.  This  anterior  projection  of  the  posterior  vaginal  wall 
is  what  I  have  styled  the  vaginal  promontory  in  the  enumeration  of  the 
influences  supporting  the  uterus.  Like  the  third  factor  mentioned,  it  is 
not  powerful,  but,  like  it,  it  is  too  important  to  be  overlooked.  It  must  be 
borne  in  mind  that  the  support  of  the  uterus  is  not  accomplished  by  one 
or  two  powerful  factors  alone,  but  by  a  combination  of  several,  each  work- 
ing towards  a  common  end. 

This  very  fact  makes  it  manifest  that  a  number  of  mechanical  influ- 
ences may  force  an  organ  thus  sustained  upwards,  downwards,  laterally, 
or  even  bend  it  upon  itself  or  turn  it  completely  inside  out,  and  that  the 
direction  of  the  impelling  force  or  nature  of  the  loss  of  support  will  deter- 
mine the  character  of  the  displacement.  The  displacements  which  may 
thus  result  have  received  the  following  appellations : — 

Ascent ; 

Descent  or  prolapsus ; 

Anteversion  ; 

Anteflexion ; 

Retroversion; 

Retroflexion : 

Lateroversion  ; 

Lateroflexion ; 

Inversion. 
These  varieties  should  not  be  memorized  by  the  student,  for  such  an 
effort  would  be  uncalled  for.  Let  him  suppose  any  pear-shaped  bag,  one 
of  gutta-percha  for  instance,  suspended  by  yielding  supports  in  a  cavity, 
and  it  must  be  evident  that  these  and  only  these  changes  of  position  could 
be  impressed  upon  it. 

Having  said  this  much  in  a  general  way  as  to  displacements,  let  me 
say  a  few  words  with  special  reference  to  uterine  flexions. 

Version,  or  turning  of  the  uterus,  signifies  the  fact  that  its  long  axis 
has  changed  its  normal  direction  in  the  pelvis.  Flexion  signifies  the  bend- 
ing of  the  uterus  upon  itself,  so  that  a  decided  angle  is  created  in  its  long 
axis.  One  condition  is  a  displacement  ;  the  other  a  deformity  in  the 
organ.  One  may  be  likened  to  a  dislocation  of  one  of  the  long  bones  ; 
the  other  to  a  fracture  with  angular  union  of  the  broken  extremities.  The 
24 


370  DISPLACEMENTS    OF    THE    UTERUS. 

treatment  of  one  involves  merely  restoration  of  a  dislocated  organ;  that  of 
the  other,  rectification  of  a  deformity  which  may  have  lasted  for  years  or 
may  even  have  been  congenital. 

Frequency Flexions  of  the  uterus,  that  is,  displacements,  anteriorly, 

posteriorly,  or  laterally,  in  which  the  decidedly  predominating  feature  is 
flexion  and  not  version,  are  very  common. 

In  339  displacements  Nonat       found  67  flexions. 
"    64  "  Meadows     "       54       " 

As  to  the  relative  frequency  of  anterior  and  posterior  flexions,  the  evi- 
dence is  decidedly  in  favor  of  the  former. 

In  67  cases  of  flexion  Nonat1      found  33  anteflexions  and   14  retroflexions. 
"    54     "  "        Meadows2     "       20  "  and   34  " 

"   54     "  "        Scanzoni8     "       46  "  and     8  " 

"   23     "  "        Valleix*       "       11  «  and    12 

"296     "  "        Hewitts       "     184  "  and  112 

Out  of  1670  cases  of  flexion  collected  by  Ludwig  Joseph,6  of  Breslau, 
1100  were  anterior  and  570  posterior.  Out  of  345  cases  of  flexion, 
Emmet7  found  273  to  be  anteflexion,  29  to  be  retroflexion,  and  43  to  be 
lateroflexion. 

Although  the  results  are  somewhat  conflicting,  the  preponderance  of 
evidence  very  decidedly  favors  anteflexion  over  retroflexion. 

One  reason  why  we  should  anticipate  that  retroflexion  would  be  less 
frequent  than  anteflexion,  is  that  the  natural  anterior  obliquity  of  the 
uterus  favors  the  latter  and  opposes  the  former  displacement.  Another  is 
the  fact  that  the  former  is  more  thoroughly  guarded  against  by  ligamentous 
support ;  the  round  ligaments,  running  as  they  do  from  the  horns  of  the 
uterus  to  the  vulva,  decidedly  tending  to  prevent  its  occurrence.  Not 
only  do  they  do  this ;  the  uterus,  being  kept  hy  them  in  anterior  inclina- 
tion, should  softening  of  its  structure  occur,  or  any  direct  force  be  exerted 
upon  it,  naturally  bends  forwards. 

If  this  be  so,  it  may  be  asked  why  areolar  hyperplasia  so  frequently 
results  in  retroflexion  as  well  as  in  anteflexion.  One  reason  is  because 
the  first  effect  of  the  increased  uterine  weight  attending  that  disease  is 
descent  of  the  uterus.  This  relaxes  the  round  ligaments,  tends  to  bring 
the  uterine  axis  in  coincidence  with  that  of  the  middle  of  the  pelvis,  and 
favors  retroflexion.  For  a  time  the  tendency  is  to  descent  and  coincident 
retroversion.     This  continues  until  the  progress  of  the  cervix  is  checked 

'  Mai.  de  l'Uterus,  p.  416.         ^  2  Am.  Journ.  Obstet.,  1st  vol.  p.  176. 

8  Klob,  op.  cit.,  p.  69.  4  Cusco,  These,  p.  35. 

5  Dis.  of  Women,  2d  Am.  ed.,  p.  213.  Hewitt  includes  versions  with  flexions. 
The  other  statistics  refer  to  pure  flexion. 

6  Berlin  Beitr'age  zur  Geburtshulfe  und  Gyniikologie,  vol.  ii.  part  2,  1873. 
»  Prin.  and  Prac.  of  Gynecology. 


ANATOMY.  371 

by  the  utero-saoral  ligaments.  Then  the  heavy  body  bends,  the  weak- 
ened tissue  yielding  at  the  os  internum,  and  retroflexion  results.  Another 
reason  is  that  flexion  commonly  follows  parturition,  at  which  time,  attack- 
ing an  organ  with  weakened  tissues  and  relaxed  ligaments,  it  meets  with 
an  efficient  ally  in  the  nurse,  who  favors  retroflexion  at  the  expense  of 
anteflexion  by  zealously  forcing  the  fundus  backwards  by  a  tight  obstetric 
bandage. 

Thanks  to  the  researches  of  Coste,  Pouchet,  Bischoff,  and  others,  we 
are  to-day  well  informed  concerning  the  development  of  the  uterus.  Early 
in  embryonic  life  a  little  duct  shoots  out  from  the  external  surface  of  each 
Wolffian  body.  These  pass  downwards  to  unite  and  make  a  common 
canal,  which  becomes  in  time  separated  into  uterus  and  vagina.  Very 
soon  a  constriction  appears,  the  neck  of  the  uterus  is  formed,  and  becomes 
well  developed,  while  a  very  small  spot  marks  the  point  where  the  body 
is  to  show  itself.  The  original  canals  become  Fallopian  tubes,  and  at  the 
time  of  birth  these,  as  well  as  the  neck  and  body  of  the  uterus,  vagina, 
and  other  organs,  have  arrived  at  maturity.  But  it  must  not  be  supposed 
that  the  proportions  of  the  adult  uterus  exist  in  that  of  infancy.  The 
neck  forms  three-quarters  of  the  organ,  and  the  body,  represented  by  a 
soft  movable  membrane,  has  no  fixed  position,  but  follows  the  bladder,  if 
upon  opening  the  abdomen  it  is  drawn  forwards,  or  the  rectum,  if  that 
viscus  is  pushed  backwards.  Later  in  the  life  of  the  girl,  even  after  she 
has  reached  puberty  and  menstruation  has  occurred,  the  uterus  is  curved 
forwards;  and  this  anterior  inflexion  lasts  through  life,  if  a  normal  state 
continue,  though  it  is  generally  diminished  and  sometimes  overcome  by 
puberty  and  utero-gestation. 

In  1849,  Velpeau,  whose  insight  into  gynecology  was  certainly  remark- 
able, in  a  discussion  before  the  Academy  of  Medicine  of  Paris,  declared 
that  he  had  so  often  found  an  anterior  inflexion  of  the  uterus  in  healthy 
women,  that  he  was  inclined  to  look  upon  it  as  normal.  Upon  this  hint 
two  of  his  pupils,  Boullard  (1852),  and  Piachaud  (1853),  with  great 
assiduity,  investigated  the  subject,  and  determined  that  it  is  so  in  the 
child  and  virgin;  the  latter  basing  his  deductions  upon  107  cases.  Boul- 
lard found  it  to  exist  in  80  female  foetuses,  and  in  27  adult  females.  Ver- 
neuil  and  Follin  subsequently  confirmed  these  observations. 

That  this  is  the  normal  condition  up  to  puberty  is  unquestionable ;  nor 
can  it  be  denied  that  to  a  limited  degree  it  is  so  even  afterwards  in  the 
unmarried  female.  But,  as  Cusco  has  pointed  out,  it  greatly  diminishes 
at  puberty,  unless  abnormal  flexion  is  developed.  Up  to  this  time  the 
neck  of  the  uterus  represents  three-quarters  of  its  entire  bulk,  and  the 
whole  organ  is  an  insignificant  element  of  the  human  body.  At  this  time, 
however,  it  becomes  an  important  organ.  The  body  develops;  its  walls 
become  thick,  dense,  and  strong;  "and,"  says  Cusco,  "this  is  an  import- 
ant point,  if  the  development  is  regular  its  walls  establish  an  equilibrium  ; 


372  DISPLACEMENTS    OF    THE    UTERUS. 

the  uterus  straightens  itself;  its  anterior  concavity  disappears ;  and  there 
remains  only  a  slight  depression  corresponding  to  the  bladder."  Up  to 
this  period  of  life  curvature  is  unquestionably  due  to  the  want  of  tone  and 
power  which  characterizes  undeveloped  uterine  tissue,  for  even  when  ante- 
flexion does  not  exist,  the  organ  is  generally  otherwise  displaced.  Thus, 
M.  Soudry,1  in  71  post-mortem  examinations  of  infants,  found  the  uterus 
anteflexed  41  times,  anteverted  11  times,  retroverted  15  times,  retroflexed 
twice,  and  retroverted  with  anteflexion  twice.  We  may  then  conclude 
from  the  evidence  at  present  upon  record — 

1st.  That  anteflexion  is  the  rule  during  early  childhood  ; 

2d.  That  it  is  quite  frequent,  in  slight  degree,  in  nulliparous  women, 
without  constituting  disease. 

For  the  prevention  of  versions  certain  pelvic  ligaments  are  very  effectual, 
but  they  have  no  power  to  prevent  bending  of  the  uterus  upon  itself.  This 
is  accomplished  by  the  inherent  strength  and  resistance  of  the  proper  tissue 
of  the  organ.  Remove  a  normal  uterus  from  the  cadaver,  balance  it  upon 
the  cervix,  and  it  will  sustain  itself  perfectly ;  press  it  down  by  applying 
force  to  the  fundus,  and  its  own  resiliency  will  cause  it  to  erect  itself  im- 
mediately. Suppose  a  uterus  to  be  composed  of  gutta-percha  instead  of 
living  tissue  ;  the  material  forming  the  walls  of  the  neck  will  support  the 
fundus  when  the  pear-shaped  bag  is  held  by  the  stem  or  narrow  part.  To 
carry  the  simile  further,  so  long  as  the  proper  tissue  of  the  stem  or  neck 
remains  normally  strong,  flexion  will  be  impossible  unless  its  resistance  be 
overcome  by  direct  physical  force  exerted  by  pressure  or  traction.  But  if 
some  influence  be  brought  to  bear  locally,  so  as  to  soften  the  part  sustain- 
ing the  fundus,  it  is  evident  that,  as  the  gutta-percha  walls  grow  weak, 
there  may  be  a  flexion  of  the  fundus  from  its  own  weight.  It  will  be  said 
that  these  views  represent  the  uterus  as  supported  by  the  vagina,  and 
leave  out  of  consideration  the  broad  ligaments  which  sustain  the  fundus. 
If  these  ligaments  were  tightly  drawn  cords,  I  could  admit  their  action, 
but  as  they  are  merely  lax  folds  which  are  not  made  tense  by  the  bending 
of  the  uterus  upon  itself,  I  do  not  do  so. 

A  corroboration  of  this  view  is  found  in  the  frequency  of  flexions  in  the 
uteri  of  the  aged  which  have  lost  tone  and  strength.  "  In  aged  women," 
says  Klob,2  "  with  exceedingly  relaxed  uteri,  the  pressure  of  the  intestines 
upon  the  posterior  surface  of  the  organ  is  sufficient  to  cause  anteflexion." 

Pathology Flexions  may  be  congenital  or  accidental.  As  the  oppo- 
site walls  develop,  an  excess  of  nutrition  may  be  appropriated  by  one, 
which  grows  rapidly,  while  the  other  developing  more  slowly  arrests  the 
erection  of  the  uterus,  and,  giving  it  an  inflexion,  creates  a  concavity  on 
one  side  and  a  convexity  on  the  other.  If  the  posterior  wall  develop  most 
decidedly,  an  anteflexion  results;  if,  as  was  the  case  in  nineteen  out  of  M. 

•  Aran,  op.  cit.,  p.  981.  *  Op.  cit.,  p.  61. 


ANATOMY.  373 

Soudry's  seventy -one.  autopsies  of  infants,  posterior  displacement  exist, 
and  the  anterior  wall  receive  the  chief  amount  of  nutrition,  a  retroflexion 
is  the  consequence.  But  not  only  does  the  excessive  growth  of  one  wall 
create  an  inflexion  on  the  opposite  side  ;  the  side  which  is  bent  undergoes 
to  a  certain  extent  atrophy,  and  this  increases  the  already  growing  dispro- 
portion. This,  in  all  probability,  is  the  source  of  congenital  flexion,  a 
condition  always  exceedingly  difficult  of  cure,  but  fortunately  one  which 
does  not  create  as  much  corporeal  congestion  and  constitutional  disturbance 
as  the  more  remediable  form  which  is  accidental. 

In  the  supplement  to  the  second  volume  of  Herbert  Spencer's  work  upon 
Biology,  appear  some  remarks  upon  the  influence  of  prevailing  winds  upon 
the  growth  of  trees,  which  are  interesting  in  this  connection.  The  tree, 
says  he,  being  habitually  bent  in  one  direction,  its  nutrition  is,  on  the 
concave  surface,  impaired,  the  ligneous  material  upon  the  convex  portion 
is  deposited  in  excess,  and  in  consequence  the  heart  of  the  tree  is  not  cen- 
tral, but  considerably  nearer  to  the  concave  than  to  the  convex  surface. 
Upon  experimenting  upon  growing  twigs  by  bending  them  to  one  or  the 
other  side,  he  found  that  he  could  uniformly  produce  the  same  result. 
"When  the  uterus  is  flexed,  a  similar  change  will  be  found  to  occur  from  a 
like  cause. 

Congenital  anteflexion  is  much  more  common  than  congenital  retro- 
flexion. Cases  of  the  latter  are,  however,  by  no  means  unknown.  Boivin 
and  Duges1  report  two  cases,  Dubois  one,  Deville  one,  and  Bell  one  in  a 
very  young  girl.     I  have  several  times  met  with  it. 

Any  influence  which  weakens  the  tissue  constituting  the  uterine  walls, 
creates  flexion.  If  the  posterior  wall  be  chiefly  affected,  the  body  falls 
backwards;  if  the  anterior,  it  inclines  forwards;  if  both,  the  direction  of 
inclination  is  decided  by  extraneous  forces.  Eokitansky  has  proved  that 
such  weakening  is  accomplished  by  endometritis,  which  creates  an  inward 
growth  of  the  utricular  glands  into  the  submucous  connective  tissue,  near 
the  os  internum,  which  in  consequence  undergoes  atrophy  and  enfeeble- 
ment ;  or  by  cystic  degeneration  in  the  cervical  glands,  "which,  from  their 
increased  size  and  subsequent  pressure,  cause  the  submucous  stratum  to 
become  atrophied,  and  which  ultimately  bursting,  thereby  cause  a  col- 
lapse of  tissue  in  the  formerly  dense  framework  of  the  uterus,  leaving  in 
its  place  a  flaccid  net-like  areolar  tissue  incapable  of  sustaining  the  organ 
in  its  normal  position."  Both  these  occurrences,  says  Klob,  take  place 
quite  frequently.  Rokitansky  says  that  in  the  anterior  semicircle  of  the 
uterine  tissue  around  the  os  internum  of  women  who  have  borne  many 
children,  a  large  transverse  vein  is  found,  which,  by  its  removal  of  tissue, 
weakens  the  wall. 

But  there   are   other    influences  which   may  accomplish    this   result : 

1  Cusco,  op.  cit.,  p.  34. 


374  DISPLACEMENTS    OF    THE    UTERUS. 

abscess  of  the  uterine  tissue ;  development  of  fibroids  which  disorder  the 
bloodvessels  ;  varicose  degeneration  of  the  veins  and  sponginess  of  tissue 
engendered  by  prolonged  traction  upon  the  neck  ;  disturbance  of  nutri- 
tion by  flexure  created  suddenly  by  a  blow  or  fall,  or  gradually  by  traction 
from  false  membranes ;  subinvolution,  or  areolar  hyperplasia,  which  ac- 
complishes, on  a  large  scale,  the  substitution  "  for  the  dense  framework  of 
the  uterus  of  a  flaccid,  net-like  areolar  tissue,  incapable  of  sustaining  the 
organ,"  which  Rokitansky  declares  occurs  at  the  os  internum  in  cystic 
degeneration. 

This  loss  of  power  in  one  or  both  walls  of  the  uterus  is  frequently, 
though  not  universally,  the  cause  of  flexions  of  accidental  character. 
They  are  sometimes  due  to  force  sufficiently  strong  to  overcome  the  resist- 
ing power  of  the  uterine  tissue,  either  suddenly  or  by  slow  degrees.  Once 
flexed,  one  wall  soon  undergoes  degeneration,  and  thus  two  causes  for  a 
continuation  of  the  condition  are  combined. 

The  point  of  greatest  weakness  is  the  point  at  which  flexion  occurs,  and 
this  is  usually  opposite  the  os  internum.  In  anteflexion  it  may  occur 
below  this  point,  when  the  neck  only  is  flexed,  from  prolonged  and  habitual 
constipation.  In  both  retroflexions  and  anteflexions  I  have  known  it  to 
occur  at  the  middle  of  the  body,  and  escape  superficial  examination,  or 
induce  a  belief  in  the  existence  of  fibrous  tumor.  Klob  has  noticed  this 
but  once,  and  has  failed  to  find  an  analogous  instance.  Cusco1  records 
one  case  in  his  own  experience  where  the  body  was  equally  divided  by  a 
flexion,  and  quotes  Ashwell  and  Bell  for  others  of  similar  character. 

These  are  the  influences  under  which  flexion  is  induced.  No  sooner 
does  it  occur,  than  a  marked  change  takes  place  in  the  uterine  circulation. 
The  uterine  bloodvessels  arise  from  the  arteria  uterina  hypogastrica,  the 
arteria  uterina  aortica,  and  from  the  arteria  spermatica  externa.2  The 
veins  make  up  by  their  union  two  plexuses,  the  uterine  and  pampiniform. 
All  these  vessels  go  to  and  come  from  the  uterus  at  its  sides.  A  flexion 
of  this  organ  to  a  certain  extent  ligates  these  vessels,  as  Hewitt  expresses 
it,  and  interferes  with  circulation  directly  and  immediately.  The  incom- 
pressible arteries  still  carry  blood  to  the  body,  but  the  compressible  veins 
fail  to  return  it  to  the  general  circulation,  and  the  consequences  are  con- 
gestion, oedema,  and,  in  time,  hypergenesis  of  tissue.  This  important  fact 
Hewitt,  in  his  recent  admirable  edition  of  his  work  upon  Diseases  of 
"Women,  lays  so  much  stress  upon,  as  to  make  it  the  pivotal  point  of  his 
pathological  creed.  There  can  be  no  question  of  the  truth  of  this  view, 
nor  of  its  extremely  important  pathological  bearing.  In  bringing  it 
prominently  forward,  and  insisting  upon  its  frequent  and  striking  effects 
as  :i  factor  in  uterine  disorders,  Hewitt  has,  in  my  judgment,  done  a 
great   deal  of  good.      He   is  in   error,  however,  in  supposing  that  it  had 

1  Op.  cit.,  p.  37.  2  Strieker's  Manual  of  Histology. 


RESULTS    AND    COMPLICATIONS.  375 

previously  been  unrecognized,  as  the  following  passage  from  his  work 
announces  :  "  It  is  somewhat  snrprising  that  the  occurrence  of  mechanical 
congestion  of  the  body  of  the  uterus,  arising  from  mere  change  of  shape 
of  the  organ,  as  above  pointed  out,  should  not  have  attracted  the  atten- 
tion of  uterine  pathologists."  Since  the  appearance  of  Klob's  work  on 
Pathological  Anatomy,  published  in  1808, '  it  had  especially  attracted  my 
attention,  and  had  constituted  a  prominent  feature  in  my  teachings.  Klob2 
declares  that  "a  further  consequence  of  venous  hyperemia,  arising  from 
hindered  reflux  of  blood  at  the  point  of  flexion,  is  oedema  with  tumefac- 
tion and  genuine  hypertrophy  of  the  body  of  the  uterus.  The  reflux  of 
blood  from  the  uterine  to  the  hypogastric  veins  is  interrupted,  and  in  con- 
sequence of  the  collateral  hyperamiia,  frequently  a  very  considerable  dila- 
tation of  the  plexus  pampiniformis  takes  place,  because  the  blood  can  now 
only  flow  through  the  spermatic  vein."  Under  this  mechanical  influence 
both  neck  and  body  become  tumid,  tender,  and  painful ;  the  mucous  lining 
is  so  congested  as  to  give  forth  excessive  amounts  of  mucus  and  blood ; 
and  the  tissues  of  the  organ,  excited  to  excessive  growth  by  prolonged 
blood  stasis,  undergo  in  time  marked  hypergenesis. 

At  the  point  of  flexion  the  cervical  canal  is  always  more  or  less  closed 
by  apposition  of  its  walls.  From  this  cause  the  ingress  of  fluids  is  pre- 
vented, and  sterility  commonly  results,  and  the  egress  is  interfered  with 
to  such  an  extent  that  dysmenorrhcea,  hematometra,  hydrometra,  and 
accumulations  of  mucus  take  place.  Of  course  such  accumulations  cannot 
occur  with  impunity ;  they  result  in  the  production  of  endometritis  and 
even  in  hematocele  by  regurgitation. 

In  congenital  flexion  the  circulation  of  the  uterus  is  so  gradually  inter- 
fered with  that  marked  congestion  is  not  so  likely  to  occur  as  it  is  when 
the  organ  is  suddenly  bent  upon  itself,  nor  is  occlusion  of  the  cervix  ordi- 
narily so  complete. 

Results  and    Complications Already   the  reader  can   enumerate  for 

himself  many  of  the  consequences  arising  from  flexion  of  the  uterus ;  and 
a  list  of  them  placed  before  him  will  need  little  further  explanation  as  to 
the  mode  of  their  production.     They  are  the  following: — 

Congestion  ; 

Hypergenesis  of  tissue ; 

Sterility; 

Dysmenorrhea ; 

Menorrhagia ; 

Endometritis  ; 

Tendency  to  abortion ; 

1  Hewitt's  views  were  first  published  in  an  article  read  before  the  British 
Medical  Association  at  Leeds  in  1870. 

2  Op.  cit.,  p.  GO. 


376  DISPLACEMENTS    OF    THE    UTERUS. 

Hematocele ; 
Ovaritis  and  Salpingitis ; 
Pelvic  peritonitis ; 
Fluid  accumulations  in  utero ;' 
Uterine  neuralgia ; 
Cystitis  and  Rectitis ; 
Granular  degeneration. 
"When  it  is  remembered  that  each  of  these  affections  sets  up  symptoms 
and  complications  of  its  own,  it  will  be  appreciated  that  flexion  of  the 
uterus  is  a  disorder  which,  apparently  insignificant  in  itself,  is  the  source 
of  many  grave  results. 

Deranged  uterine  circulation  produces  menstrual  disorder.  Usually 
this  consists  in  excessive  flow,  but  sometimes  the  opposite  condition 
exists. 

Ovarian  congestion,  neuralgia,  and  enlargements,  as,  likewise,  catarrh 
of  the  Fallopian  tubes,  are  probably  due  to  a  reflex  influence  transmitted 
through  the  intimate  and  sensitive  nervous  connections  between  the  uterus 
and  these  organs.  Rigby  attributed  them  to  pressure,  but  this  does  not 
appear  to  account  for  those  conditions. 

Peritonitis  results  from  pressure  and  friction  by  the  displaced  fundus, 
and,  in  some  cases,  from  reflux  through  the  tubes  of  imprisoned  fluids. 
It  is  by  no  means  rare;  so  common  is  it,  indeed,  that  Virchow  regards 
traction  by  false  membranes  as  the  chief  cause  of  anteflexions.  That  this 
pathologist  is  in  error  upon  this  point  is  the  belief  of  all  others  with  whose 
views  1  am  familiar. 

Etiology  of  Uterine  Displacements Both  in  didactic  and  clinical  teach- 
ing I  have  for  many  years  grouped  the  causes  of  uterine  displacement  in 
the  manner  about  to  be  described.  Enlarged  experience  with  the  method 
leads  me  to  regard  it  with  increased  favor,  and  I  would  urge  its  claims  to 
adoption,  by  teachers  and  students.  By  it  no  influence  producing  displace- 
ment escapes  classification,  and  it  induces  him  who  employs  it  to  arrange 
the  subject  systematically  in  his  mind. 

The  general  causes  of  uterine  displacement  may  thus  be  tabulated: — 
1st.  Any  influence  which  increases  the  weight  of  the  uterus  ; 
2d.    Any  influence  which  enfeebles  the  supports  of  the  uterus  ; 
3d.    Any  influence  which  displaces  the  uterus  by  pressure  ; 
4th.  Any  influence  which  displaces  the  uterus  by  traction. 
To  state  this  more  fully  in  other  words: — 

1st.  The  uterine  supports  are  equal  to  sustaining  the  organ  when  of 
normal  weight ;  but  when  its  weight  is  increased  they  naturally  fail  in 
their  task. 

2d.    Even  if  the  uterus  be  no  heavier  than  it  should  be,  it  may  become 

'  Khvisch  reports  a  case  of  hydroinetra. 


causes.  377 

displaced  from  depreciation  of  that  support  to  which  it  is  entitled,  and 
which  was  made  to  sustain  it. 

3d.  If  both  the  uterus  and  its  sustaining  powers  be  perfectly  normal,  it 
is  evident  that  direct  or  powerful  pressure  may  overcome  the  latter,  and 
force  the  organ  from  its  place. 

4th.  It  is  equally  evident,  that,  as,  by  a  tenaculum  fastened  in  the  uterus 
of  the  cadaver,  we  may  drag  it  from  its  position,  so  may  contracting 
lymph  or  a  prolapsed  vagina  effect  this  in  a  living  body. 

All  these  facts  having  been  premised,  a  concise  view  of  the  special 
causes  of  displacements  may  be  thus  presented. 

1.  Influences  increasing  weight  of  uterus. 

Congestion  ; 

Tumors  in  the  walls  or  cavity ; 

Pregnancy  ; 

Excessive  growth  of  any  of  its  component  parts  ; 

Subinvolution  ; 

Fluid  retained  in  cavity  ; 

Masses  of  cancer  or  tubercle. 

2.  Influences  weakening  uterine  siqiports. 

llupture  of  the  perineum  ; 

Weakening  of  vaginal  walls  ;' 

Stretching  of  uterine  ligaments  ; 

Want  of  tone  in  uterine  tissue ; 

Degeneration  of  uterine  tissue  ; 

Abnormally  large  pelvis  ; 

Any  influence  impairing  sustaining  power  of  abdomen. 

3.  Influences  pressing  the  uterus  out  oj  p>lace. 

Tight  clothing; 

Heavy  clothing  supported  on  the  abdomen  ; 

Muscular  efforts  ; 

Ascites  ; 

Abdominal  tumors  ; 

Abscesses  or  masses  of  lymph. 

Repletion  of  the  bladder. 

4.  Influences  exerting  traction  on  the  uterus. 

Lymph  deposited  in  pelvic  areolar  tissue  ; 
Lymph  deposited  on  peritoneum  of  pelvic  viscera  ; 
Cicatrices  in  vaginal  walls  ; 
Shortening  of  uterine  ligaments  ; 
Natural  shortness  of  vagina  ; 
Prolapse  of  vagina,  bladder,  or  rectum. 

1  Such  weakening  from  subinvolution  or  any  other  cause  destroys  the  support- 
ing power  of  the  vaginal  promontory. 


378  DISPLACEMENTS    OF    THE    UTERUS. 

The  mode  of  action  of  each  of  these  causes  is  so  evident  as  to  require 
no  special  mention  at  this  time,  but  they  will  be  particularly  alluded  to 
hereafter. 

No  circumstance  combines  so  many  of  these  causes  of  displacement  as 
utero-gestation  and  parturition.  Should  involution  follow  these  without 
interruption,  no  tendency  to  displacement  results.  But  the  process  of  in- 
volution is  frequently  interfered  with.  Then,  as  consequences  of  the  arrest 
of  retrograde  metamorphosis,  the  uterus  remains  large  and  heavy  ;  the 
vagina  voluminous  and  feeble  ;  and  the  uterine  ligaments,  which  owe  their 
strength  chiefly  to  the  uterine  tissue  which  they  contain,  lax  and  weak. 
As  a  result  of  parturition,  too,  the  perineum  is  often  enfeebled,  which 
allows  of  prolapse  of  the  vagina,  which  produces  traction  upon  the  uterus. 
These  remarks  apply  to  true  displacements  of  the  uterus.  To  flexions 
or  deformities  of  the  organ  itself,  they  do  not  so  sufficiently  apply  as  to 
render  uncalled  for  some  special  remarks,  which  I  now  proceed  to  offer. 

Predisposing  Causes  of  Uterine  Flexions — Any  cause  which  predis- 
poses to  enfeeblement  of  uterine  tone,  to  the  development  of  a  force  which 
overcomes  this  even  when  unimpaired,  or  still  more  one  which  combines 
the  two  evil  influences,  prepares  the  way  for  flexure  of  the  uterus  under 
the  impulse  given  by  a  sudden  or  persistent  exciting  cause.  They  may 
be  thus  enumerated  : — 

Parturition  ; 

Impoverishment  of  the  blood  ; 

Enfeebled  nerve  state  ; 

Extreme  youth  or  age  ; 

Laborious  occupation  ; 

Relaxation  of  abdominal  walls  ; 

Influences  altering  pelvic  axes. 
Exciting  Causes. — One  of  the  functions  of  the  cervix  uteri  is  to  support 
the  body,  and  for  the  performance  of  this  it  is  abundantly  competent,  un- 
less its  powers  be  impaired  by  one  of  the  following  influences : — 
Influences  weakening  uterine  support. 

Endometritis ; 

Cystic  degeneration  near  os  internum  ; 

Pregnancy ; 

Fatty  degeneration  ; 

Areolar  hyperplasia ; 

Vascular  degeneration  in  uterine  walls. 
Influences  increasing  the  weight  of  the  fundus. 

Enlargement  of  the  body  ; 

Pregnancy ; 

Tumors ; 

Accumulation  of  fluid  in  utero. 


causes.  379 

Influences  pushing  the  fundus  or  cervix  forwards  or  backwards. 

Abdominal  or  pelvic  tumors  ; 

Ascites ; 

Fecal  accumulation  ; 

Tight  clothing ; 

Muscular  efforts. 
Influences  exerting  traction  forwards  or  backwards. 

False  membranes  from  pelvic  peritonitis. 
Of  the  first  class  of  causes,  inflammation  affecting  the  mucous  membrane 
of  the  neck  and  creating  areolar  hyperplasia  in  the  parenchyma  is,  accord- 
ing to  my  experience,  one  of  the  most  frequent.  The  hyperplasia  thus  arising 
results  in  atrophy  of  the  muscular  and  submucous  fibrous  structures  of  the 
uterus  and  their  replacement  by  hypertrophied  areolar  tissue,  and  produces 
a  marked  tendency  to  this  deviation  by  thus  substituting  a  lax  and  feeble 
for  a  dense  and  powerful  substance.  Klob  declares  that  this  replacement 
of  strong  tissue  by  that  which  is  weaker  occurs  more  especially  near  the 
os  internum.  Virchow  denies  the  agency  of  this  condition  as  a  causative 
influence,  as  he  likewise  does  that  of  fatty  degeneration,  observed  by 
Scanzoni,  at  the  point  of  flexure.  The  influence  of  parturition,  abortion, 
and  pregnancy  has  been  admitted  by  all  authorities. 

The  varieties  coming  under  the  head  of  the  second  set  of  causes  are  all 
universally  admitted,  as  are  also  those  belonging  to  the  third.  Fecal  im- 
paction may  possibly  produce  flexion  of  the  body,  and  frequently  causes 
the  cervix  to  bend  sharply  forwards.  The  fourth  set  of  causes  is  put 
beyond  question,  by  the  fact  that  in  autopsies  the  uterus  is  often  found 
thus  bound  in  a  state  of  flexion. 

The  etiology  of  cervical  flexion  is  somewhat  different  from  that  of  cor- 
poreal. It  is,  I  feel  satisfied,  generally  induced  by  pressure  directly  ex- 
erted upon  the  uterus  by  tight  clothing,  which  forces  it  against  the  concave 
surface  of  the  vagina.  This  surface  gives  the  impinging  part  a  slant  for- 
wards, and  keeps  it  thus  bent.  Habitual  constipation  increases  this  vicious 
curve,  and  the  two  causes  combined  often  result  in  this  unmanageable  form 
of  the  affection.  This  explains  the  fact,  which  all  must  have  noticed,  that 
in  pure  corporeal  flexion  the  uterus  is  often  high  up  in  the  pelvis,  while 
in  that  of  cervical  form  it  is  almost  invariably  low  down.  It  likewise  ex- 
plains what  my  observation  leads  me  to  regard  as  a  fact,  that  in  nullipa- 
rous  women  the  cervical  and  cervico-corporeal  varieties  preponderate  in 
frequency  over  the  corporeal  form,  which  is  generally  met  with  in  multi- 
parous  women. 

There  is  still  another  pathological  element  which  enters  into  the  eti- 
ology of  cervical  flexions,  and  explains  the  phenomena  with  regard  to  them 
which  I  have  just  mentioned.  The  uterus  being  forced  downwards  by 
influences  exerting  themselves  upon  the  abdomen,  if  the  utero-vesical 
ligaments  be   lax  and  yielding,  corporeal  flexion  will   occur,  the  cervix 


380  DISPLACEMENTS    OF    THE    UTERUS. 

retreating  under  pressure.  If,  however,  these  ligaments  keep  the  cervix 
in  close  contact  with  the  bladder,  cervico-corporeal  or  pure  cervical  flexion 
will  be  developed.  Parturition  does  more  to  stretch  these  ligaments  than 
anything  else,  and  thus  cervical  flexion  is  not  so  generally  met  with  in 
women  who  have  gone  through  that  process  as  in  those  who  have  not. 
Corporeal  flexion  is  the  variety  seen  after  parturition  ;  the  cervical  and 
cervico-corporeal  forms,  those  which  we  see  in  nulliparous  women.  Not 
only  is  this  fact  interesting  in  reference  to  pathology ;  it  has  an  impor- 
tant bearing  upon  the  treatment  of  cervical  flexions.  He  who  would  treat 
these  cases  successfully  must  systematically  stretch  the  ligaments  which 
keep  the  cervix  in  an  anterior  position,  and  by  this  means  strive  to  change 
the  form  of  displacement  to  that  of  corporeal  flexion,  or  of  anteversion. 

Retroflexion  is  most  frequently  the  result  of  some  influence  which 
weakens  the  tone  of  the  uterine  walls,  but,  even  when  this  is  normal,  any 
force  directly  applied  may  displace  it  and  produce  a  flexure,  whether  such 
force  is  developed  suddenly  or  gradually. 

"We  have  now  pursued  the  study  of  flexions,  as  a  whole,  as  far  as  it  is 
profitable  to  do  so ;  and  from  this  point,  they  shall  be  considered  under 
separate  heads. 

The  uterus  may  be  flexed  upon  itself  anteriorly,  posteriorly,  or  laterally, 
giving  rise  to  the  disorders  known  as — 

Anteflexion  ; 

Retroflexion  ; 

Latero-flexion. 
The  fundus  in  falling  forwards  or  backwards  does  not  always  preserve 
the  median  line,  but  commonly  falls  obliquely  to  the  right  or  left.  This 
obliquity  is  frequently  created,  even  where  the  median  line  was  orignally 
preserved,  by  the  use  of  a  pessary,  and  constitutes  so  prominent  a  difficulty 
in  these  cases  that  I  employ  a  special  instrument  for  its  treatment. 

Thus  we  may  find  a  uterus  flexed  forwards  and  laterally;  backwards 
and  forwards ;  backwards  and  laterally,  etc. 
These  varieties  are  known  as — 

Retro-anteflexion  ; 

Retro-lateroflexion ; 

Ante-retroflexion  ; 

Latero-anteflexion,  etc. 
The  student  need  not  memorize  these,  but,  merely  keeping  in  mind  the 
fact  that  such  combinations  are  possible,  he  will  readily  recognize  them  at 
the  bedside  if  he  have  mastered  the  three  chief  forms. 

This  is  all  that  need  be  said  upon  the  subject  of  uterine  displacements 
in  general.  I  shall  now  proceed  to  complete  the  outline  here  sketched, 
and  to  go  into  the  details  connected  with  each  variety  of  the  affection. 


ASCENT  AND  DESCENT  OF  THE  UTERUS.        381 


CHAPTER    XXVI. 

ASCENT  AND  DESCENT  OF  THE  UTERUS. 

Ascent  of  the  Uterus. 

In  its  normal  condition  the  uterus  descends  into  the  pelvic  cavity  so  as 
to  assume  a  position  about  two  inches  from  the  vulva.  If  its  weight  be 
augmented,  it  comes  much  lower  than  this,  and  continues  to  do  so  as  its 
volume  increases,  until  its  development  becomes  so  great  that  it  cannot  be 
accommodated  by  the  pelvis.  Then  it  escapes  from  the  cavity  by  ascend- 
ing to  a  more  capacious  space  above  the  superior  strait.  This  change 
occurs  in  every  normal  pregnancy.  During  the  first  three  months  the 
uterus  falls  in  the  pelvis,  being  in  a  state  of  prolapse.  As  the  fourth 
month  approaches  its  volume  becomes  so  great  that  it  can  no  longer  be 
retained  in  the  pelvic  cavity,  and  then  it  escapes  above  the  superior  strait 
where  sufficient  space  is  afforded  for  it  to  undergo  full  development.  This 
is  not  only  so  in  pregnancy  ;  the  uterus  is  similarly  affected  by  morbid 
growths.  When,  under  these  circumstances,  it  leaves  the  pelvis,  the  fact 
is  expressed  by  the  term  ascent. 

Ascent  of  the  uterus  is  never  an  original  disease,  but  the  result  of  some 
important  change  connected  with  that  organ,  and  requires  merely  a  men- 
tion. It  may  occur  whenever  a  tumor  is  developed  in  connection  with 
the  vagina,  rectum,  or  recto-vaginal  cul-de-sac,  when  there  exists  a  growth 
in  the  walls  or  cavity  of  the  uterus  which  renders  it  too  large  for  accommo- 
dation in  the  pelvis,  or,  when  an  abdominal  tumor  draws  up  the  uterus. 
It  never  requires  treatment,  and  is  of  importance  only  as  exciting  suspi- 
cion of  pregnancy,  or  as  an  evidence  of  morbid  growth  in  some  way  con- 
nected with  the  organs  of  generation. 

Descent  or  Prolapsus  of  the  Uterus. 

Definition,  Synonyms,  and  Frequency — The  name  of  this  disorder 
defines  its  character  writh  sufficient  clearness.  It  is  of  frequent  occurrence, 
and  under  the  name  of  Falling  of  the  Womb  is  well  known  to  women, 
and  constitutes  for  them  an  object  of  especial  dread.  As  almost  all  women, 
after  the  period  of  fruitfulness  has  passed,  have  an  intuitive  fear  of  cancer 
of  the  uterus,  so  do  a  large  number  before  that  time  manifest  an  appre- 
hension of  prolapsus.  In  the  one  case  the  anxiety  is  fcr  life,  in  the  other 
for  usefulness  and  comfort.  • 

Unfortunately  for  the  student  of  this  subject,  its  nomenclature  has  been 


382        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

rendered  somewhat  obscure.  By  some,  all  cases  of  prolapsus  in  which 
the  uterus  does  not  escape  from  the  vagina  are  termed  incomplete,  while 
those  in  which  it  does  are  styled  complete.  By  others,  complete  protru- 
sion is  denominated  procidentia;  and,  by  others  still,  a  very  slight  descent 
without  alteration  of  direction  of  axis  has  been  designated  by  the  very  old 
name  of  squatting  uterus.  I  have  striven  to  simplify  the  matter  by  apply- 
ing the  name  prolapsus  to  all,  and  marking  the  degrees  of  descent  by  the 
terms  1st,  2d,  and  3d. 

Anatomy. — Those  uterine  supports  which  are  especially  active  in  pre- 
venting uterine  descent  are  the  surrounding  areolar  tissue,  which  binds  it 
to  the  bladder,  the  rectum,  and  the  pelvic  walls;  the  utero-vesical  and 
utero-sacral  ligaments  ;  and  the  retentive  power  of  the  abdomen.  About 
the  sustaining  influence  of  the  vagina  there  is  much  difference  of  opinion  ; 
some,  like  Savage,  denying  it ;  while  others,  like  Bennet,  West,  and 
Kiwisch,  maintain  it.  My  opinion  is,  that  the  promontory  formed  by  the 
vagina  in  front  of  the  cervix  certainly  effects  something  in  the  way  of 
support,  although  observation  has  led  me  to  modify  very  much  the  belief 
which  I  once  had  in  the  general  sustaining  influence  of  the  canal.  Loss 
of  tone  in  it,  resulting  in  prolapsus  vagina?,  is  commonly  attended  by  a 
similar  prolapse  in  the  uterus,  but  it  does  not  follow  that  the  uterus  falls 
from  want  of  support ;  it  is  more  probably  dragged  down  by  the  heavy 
vagina.  This  view  may  be  sustained  by  so  many  strong  arguments  that 
it  need  not  invoke  weak  ones.  A  good  deal  of  stress  has  been  laid  upon 
an  experiment  for  which  Aran  credits  Stoltz  ;  that  of  cutting  the  vagina 
away  without  noting  any  descent  of  the  uterus.  A  little  reflection  must 
show  that  this  proves  almost  nothing.  It  merely  demonstrates  the  fact 
that,  without  the  vagina,  other  supports  are  sufficient  to  sustain  the  uterus. 
No  one  has  ever  maintained  that  the  vagina  was  the  only  support  which 
keeps  the  uterus  up,  nor  that  others  were  insufficient  without  it. 

A  great  deal  of  support  is  unquestionably  derived  from  the  connective 
areolar  tissue,  which  so  closely  unites  the  uterus  with  the  rectum,  bladder, 
and  pelvic  walls,  as  to  involve  displacement  of  these  viscera  in  its  descent. 
Dr.  Savage,  dragging  the  uterus  of  a  cadaver  forcibly  downwards  by 
means  of  a  vulsellum  attached  to  the  neck,  found  that  after  cutting  its 
important  ligaments,  and  overcoming  by  force  the  action  of  the  vagina,  it 
still  would  not  advance.  "  The  obstruction  was  found  to  be  due  to  the 
subperitoneal  pelvic  cellular  tissue,  particularly  where  it  surrounds  and 
accompanies  the  uterine  bloodvessels." 

The  most  important  factors  in  the  prevention  of  prolapse  are  the  utero- 
sacral  ligaments,  which  Aran  considered  the  only  real  ligaments  of  the 
uterus.  Arising  from  the  point  of  junction  of  neck  and  body,  they  usually 
embrace  the  rectum  in  their  bifurcation  posteriorly,  and,  diverging  on  each 
side  of  it,  terminate  in  the  subperitoneal  cellular  tissue,  as  high  up  as  the 
second  lumbar  vertebra.     They  are  exceptionally  inserted  into  the  rec- 


CAUSES  OF  PROLAPSUS  UTERI.  383 

turn.  It  was  the  recognition  of  this  anatomical  arrangement  of  these  im- 
portant ligaments  which  led  Iluguier  to  suggest  that  they  he  called  utero- 
lumhar,  instead  of  utero-sacral.  They  consist  of  the  following  elements  : 
peritoneum,  pelvic  connective  tissue,  uterine  cortex,  and  vaginal  muscular 
fibre.  Their  influence,  as  likewise  to  a  much  less  degree  that  of  two 
similar  bands  connecting  the  cervix  in  front  with  the  bladder,  cannot  be 
doubted. 

These  are  probably  all  the  factors  which  unite  in  the  prevention  of  pro- 
lapsus in  the  first  and  second  degrees.  When  they  are  entirely  overcome 
and  the  descent  has  become  complete,  the  round  and  broad  or  lateral  liga- 
ments come  into  action,  but  not  until  that  has  occurred. 

Varieties This  displacement  may  occur  very  suddenly  and  unexpect- 
edly, or  gradually  and  by  successive  steps.     As  the  symptoms  of  the  two 
varieties  differ  only  in  the  rapidity  and  severity  of 
their  development,  and  the  second  is  much  the  more  Fig.  140. 

frequent,  I  shall  direct  my  remarks  chiefly  to  it, 
and  describe  the  first  in  a  few  words  in  an  appro- 
priate place. 

Prolapsus  may  exist  either  in  the  first,  second,  or 
third  degree,  the  direction  of  the  uterine  axis  in 
each  of  which  is  exhibited  in  Fig.  140. 

In  the  first  the  uterine  axis  is  bent  forwards,  the 
organ  being  somewhat  anteverted  and  sunk  in  the       Diagram  representing  the 

.    .  T         .  iiiii  uterine  axis  in  the  three 

pelvis.     In  the  second  the  body  has  gone  towards     degrees  of  prolapsus. 
the  sacrum,  the  cervix  having  come  down   to  the 

ostium  vaginae.     In  the  third  the  last  barrier  has  been  overcome,  and 
either  a  part  or  the  whole  of  the  uterus  hangs  between  the  thighs. 
Causes — The  causes  which  predispose  to  this  accident  are — 

Child  bearing ; 

Laborious  occupations ; 

Advanced  age ; 

Habitual  constipation. 
I  know  of  no  way  in  which  I  can  give  so  concise  a  summary  of  the  ex- 
citing causes  of  prolapsus  as  by  a  reference  to  the  classification  to  which  I 
have  already  referred  under  general  considerations  upon  displacements ; 
for  the  exciting  causes  will  be  found  to  belong  in  every  case  to  one  of  four 
classes :  those  increasing  uterine  weight  ;  those  enfeebling  uterine  sup- 
ports ;  those  forcing  the  uterus  down  by  power  applied  above  ;  and  those 
drawing  it  down  by  traction  from  below. 

a.  Examples  of  causes  connected  with  increased  uterine  weight : — 

Tumors,  submucous,  subserous,  or  mural ; 

Pregnancy,  (rare,  but  sometimes  met  with)  ; 

Hypertrophy  or  hyperplasia ; 

Retained  fluid. 


384        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

b.  Examples  of  causes  connected  with  enfeeblement  of  uterine  sup- 
ports : — 

Abnormally  capacious  pelvis ; 
Destruction  of  power  of  the  perineum  ; 
Loss  of  tone  in  vaginal  walls  ; 
Loss  of  tone  in  uterine  ligaments  ; 
Absorption  of  fat  from  pelvic  areolar  tissue; 
Atony  of  abdominal  muscles  ; 
Diminution  of  power  of  respiratory  muscles. 

c.  Examples  of  influences  forcing  the  uterus  downwards  : — 

Violent  coughing ; 
Tumors  in  abdomen  ; 
Ascites ; 

Violent  muscular  efforts ; 
Tight  and  heavy  clothing  ; 
Straining  at  stool. 

d.  Examples  of  influences  dragging  the  uterus  down  : — 

Congenital  or  acquired  shortness  of  the  vagina  ; 

Prolapse  of  vagina,  bladder,  or  rectum  ; 

Uterine  prolapsus. 
I  have  already  stated  that  these  evil  influences  are  most  completely 
combined  in  the  condition  existing  after  parturition,  when  the  uterus  is 
heavier  than  normal,  the  recently  distended  vagina  relaxed  and  feeble,  the 
uterine  ligaments  very  much  stretched,  and  the  sphincteric  muscles  of  the 
vagina  weakened.  "When,  as  so  often  happens,  rupture  of  the  perineum 
and  of  the  cervix  uteri  occur,  and  are  followed  by  subinvolution  of  vagina, 
uterus,  and  uterine  ligaments,  we  have  in  perfection  all  the  conditions 
which  give  rise  to  this  displacement.  Of  all  the  causes  of  prolapsus  this 
combination  is  the  most  frequent,  and  hence  the  difficulties  attending  cure. 
It  is  for  this  reason  that  prolapse  is  found  to  be  rare  in  women  who  have 
never  borne  children,  less  rare  in  those  who  have  borne  one  only,  and 
appears  to  increase  in  frequency  in  proportion  to  the  frequency  of  the 
parturient  process.  Scanzoni  reports  that  in  114  cases  of  prolapsus  99 
occurred  in  women  who  had  borne  children.  Even  the  most  complete 
prolapse,  however,  will  sometimes  be  met  with  in  young  and  unmarried 
women.  Within  the  past  five  years  I  have  met  with  three  such  cases, 
one  in  a  virgin  of  nineteen,  one  in  an  old  maid  of  about  sixty,  and  the 
third  in  a  healthy,  laboring  woman  at  the  menopause. 

Next  in  order  of  frequency  will  be  found  a  condition  which  occurs  in 
old  women,  a  loss  of  vaginal  power  from  atrophy  of  the  vagina,  and  ab- 
sorption of  the  padding  of  fat  which  normally  occupies  parts  of  the  pelvis, 
and  helps  to  aid  that  canal  in  sustaining  the  uterus.  This  condition  has 
been  specially  mentioned  by  some  of  the  German  pathologists,  and  atten- 
tion has  been  called  to  its  importance  by  Dr.  Barnes,  of  London.     Here, 


PATHOLOGY    OF    PROLAPSUS    UTERI.  385 

although  the  uterus  is  atrophied,  it  descends  in  spite  of  its  lightness,  partly 
from  loss  of  support  from  the  vaginal  promontory  and  partly  from  traction 
exerted  upon  it  by  the  prolapsing  vaginal  walls. 

An  important  position  as  a  pathological  factor  is  assumed  by  loss  of  the 
retentive  power  of  the  abdomen.  Want  of  exercise  except  in  walking  in- 
duces in  women  very  commonly  an  atonic  condition  of  the  thoracic  and 
abdominal  muscles  ;  and  the  respiratory  act  therefore  becomes  inefficient, 
and  the  piston  function  of  the  diaphragm  feeble  and  imperfect.  As  a 
consequence  of  this  failure,  the  uterus  rises  in  the  pelvis  at  each  expira- 
tion less  perfectly  than  it  ought ;  its  circulation,  lacking  the  stimulus  of  the 
abdominal  rise  and  fall,  becomes  sluggish  ;  gradually  it  settles  lower  and 
lower  in  the  pelvis,  and  becomes  a  readier  prey  to  the  action  of  other  ma- 
lign influences. 

Relaxation  of  the  abdominal  walls  probably  also  favors  displacement  by 
effecting  an  alteration  of  the  direction  of  pressure  transmitted  to  the 
uterus,  bladder,  and  superior  vaginal  wall,  and  by  permitting  the  free  en- 
trance of  intestines  into  the  anterior  peritoneal  prolongation  or  anterior 
uterine  excavation. 

Increased  uterine  weight  and  pressure  from  above  are  so  plainly  active 
in  creating  prolapsus,  that  no  one  will  doubt  their  causative  influence.  By 
its  instrumentality  we  see  complete  prolapsus  occur  with  ovarian  tumors, 
ascites,  etc. 

Pathology There  is  no  variety  of  displacement  about  the  pathology 

and  mechanism  of  which  gynecologists  are  more  at  variance  than  this, 
and  yet  none  to  which  a  greater  amount  of  honest,  scientific  labor  has 
been  applied  for  the  elucidation  of  these  very  points.  As  examples,  I  may 
cite  the  experimental  researches  of  Aran,1  Legendre,2  Huguier,3  Savage,4 
and  Taylor,5  to  which  the  seeker  after  more  elaborate  data  is  referred. 

My  limited  space  will  not  permit  me  to  go  fully  into  the  views  of  these 
investigators,  and  I  shall  confine  myself  chiefly  to  a  rather  dogmatic  state- 
ment of  my  own  opinions,  at  the  same  time  acknowledging  that  they  are, 
in  great  extent,  founded  upon  the  investigations  alluded  to. 

It  matters  not  whether  the  original  cause  of  the  displacement  be  in- 
crease of  uterine  weight,  depreciation  of  sustaining  power,  or  direct  force 
exerted  upon  the  organ  from  above  or  below;  an  invariable  result  of  its 
existence  is  diminution  of  the  power  of  the  uterine  supports.  The  liga- 
ments are  stretched,  the  vagina  distended  and  doubled  upon  itself  or 
everted,  and  the   contractile  power  of  the  sphincteric  muscles  impaired. 

'  Etudes  Anatomiques  et  Anatomo-pathologique  sur  la  Statique  de  FUterus, 
Paris,  1858,  Archiv.  Gen.  de  Med. 

2  De  la  Chute  de  l'Ute"rus,  Paris,  1860. 

3  Les  Allongements  Hypertrophiques  du  Col  de  l'Uterus,  Paris,  1859. 

4  Female  Pelvic  Organs,  London,  2d  ed.,  1870. 

5  On  Amputation  of  the  Cervix  Uteri,  etc.,  New  York,  1  S<J9. 

25 


386        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

The  displaced  organ  is  generally  affected  by  congestion  and  inflammation 
of  the  mucous  lining,  its  cavity  is  much  enlarged,  and  solutions  of  con- 
tinuity occur  upon  the  cervix.  The  vaginal  rugae  are  effaced,  and  the 
lining  of  the  canal,  exposed  to  atmospheric  influences  and  friction,  looks 
like  the  cicatrized  surface  of  scalded  skin  rather  than  mucous  membrane. 

"  The  tension  of  the  aponeurotic  fibres  of  the  broad  ligaments,"  says 
Legendre,  "  during  uterine  prolapse,  results  in  compression  of  the  hypo- 
gastric veins,  as  compression  of  the  veins  of  the  neck  occurs,  from  tension 
of  the  cervical  fascia,  when  the  head  is  forcibly  thrown  backward.  In  this 
way  congestion  of  the  uterus  and  other  pelvic  organs  is  kept  up."  Pro- 
lapsus, from  its  influence  in  thus  producing  hyperemia,  is  usually  attended 
by  hyperplasia  of  the  areolar  tissue  of  the  uterus.  This  organ  undergoes 
an  absolute  increase  in  size,  and  the  tissue  of  the  cervix  is  especially 
altered.  Simultaneously  with  hyperplasia,  there  is  varicose  degeneration 
of  the  bloodvessels  of  the  cervix  and  absorption  of  its  proper  tissue.  This 
increases  the  natural  ductility  of  the  part,  and  upon  any  traction  being 
applied  it  stretches  so  as  to  produce  the  phenomenon  of  variation  in  the 
length  of  the  uterus,  mentioned  under  the  head  of  physical  signs.  The 
walls  of  the  vagina  are  found  much  thickened  by  proliferation  of  epithelium 
and  hypertrophy  of  the  submucous  layers  of  areolar  tissue.  Thus  it  be- 
comes not  only  more  capacious,  but  heavier  and  more  voluminous  than 
normal,  and  even  if  its  increase  in  volume  and  weight  are  consequences  of 
uterine  displacement,  it  drags  upon  the  uterus  and  increases  its  tendency 
to  descend. 

The  uterus  may  descend  from  its  normal  place  in  the  pelvis  under  any 
one  of  the  four  influences  which  have  been  mentioned.  It  must  not,  how- 
ever, be  supposed  that  one  only  is  usually  active.  On  the  contrary,  two, 
three,  and  even  four  are  often  combined  in  furthering  the  result.  For 
thoroughness  of  study  they  are  examined  apart,  that  course  being  also 
chosen  from  the  fact  that  even  ifi  several  causes  are  combined,  one  is  usu- 
ally especially  prominent  as  a  factor. 

If  a  careful  clinical  study  be  made  of  this  interesting  subject,  the  ute- 
rus will  be  found  to  descend  in  one  of  these  ways : — 

1st.  A  woman  who  has  previously  been  in  good  health  begins  to  com- 
plain of  dragging  about  the  loins,  backache,  and  sense  of  fatigue  about 
the  pelvis.  An  examination  is  made,  and  the  uterus  is  found  resting  upon 
the  floor  of  the  pelvis,  its  axis  little  altered.  There  is  no  rupture  of 
perineum,  no  redundancy  of  vagina,  and  the  habits  of  life  of  the  patient 
preclude  the  possibility  of  muscular  efforts  or  tight  clothing  being  agents 
in  the  condition.  A  careful  examination  of  the  displaced  uterus  shows  it 
to  be  large  and  heavy  from  subinvolution,  or  discovers  a  fibrous  tumor  in 
its  structure.  The  natural  supports  have  been  perfect,  but  they  have 
been  overtaxed  and  have  yielded.  Increased  uterine  weight  is  the  prime 
mover  in  the  disorder. 


PATHOLOGY    OF    PROLAPSUS    UTERI.  387 

But  keep  this  case  under  observation.  The  descent  already  effected 
lias  drawn  down  the  bladder,  caused  pressure  upon  the  rectum,  established 
a  hyperemia  in  the  tissues  of  the  vagina,  and  begun  already  to  rob  the 
uterine  ligaments  of  their  power  by  stretching  them.  Pressure  on  the 
rectum  and  dragging  upon  the  bladder  create  irritation,  the  patient  "bears 
down"  in  evacuating  these  viscera,  and  a  new  influence  is  developed : 
force  from  above.  Very  soon  congestion  of  the  vagina  results  in  exces- 
sive areolar  growth,  this  canal  falls  into  its  own  distended  channel,  and 
another  evil  influence  is  the  result :  traction  upon  the  uterus  from  below. 
The  uterus  has  now  descended  so  that  its  os  projects  between  the  labia 
majora  ;  if  its  ligaments  were  stretched  before,  how  much  more  so  must 
they  be  now  ! 

2d.  A  uterus  is  found  in  the  first  degree  of  prolapsus.  It  is  a  healthy 
uterus,  normal  in  size,  weight,  and  consistency.  Its  supports  appear  per- 
fect, and  no  influence  exerts  traction  upon  it  from  below.  Everything  is 
normal,  but  one — the  uterus  has  descended.  Examination  proves  that 
this  woman  has  labored  hard,  lifting  heavy  weights,  and  placing  herself  in 
a  constrained  attitude  to  do  so ;  or  she  has  for  weeks  suffered  from  a  spas- 
modic, violent  cough ;  or  from  obstinate  constipation  which  has  caused 
tenesmus.  The  cause  of  the  prolapse  is  evidently  force  applied  to  the 
uterus  from  above.  But  this  remains  the  sole  cause  for  a  short  time  only. 
Very  soon  increased  weight  of  the  uterus  from  congestion,  enfeeblement 
of  uterine  supports  from  prolonged  tension,  and  traction  by  falling  of  the 
hypertrophied  vagina  and  prolapsed  bladder  complete  the  vicious  circle. 

3d.  An  examination  of  the  uterus  in  a  case  exactly  similar  as  to  symp- 
toms, demonstrates  no  increase  of  uterine  weight,  no  force  applied  from 
above.  The  woman  is  found  to  have  a  justo-major  pelvis,  which  has 
always  resulted  in  precipitate  labors ;  or  she  is  past  sixty,  and  a  senile 
atrophy  is  developing;  or  the  perineum  is  ruptured,  and  the  anterior  and 
posterior  vaginal  walls  are  protruding  in  egg-like  pouches  at  the  vulva, 
not  sufficiently  to  drag  upon  the  uterus,  but  enough  to  shorten  the  vagina 
by  allowing  its  distal  end  to  protrude,  and  thus  the  vaginal  promontory  is 
removed.  The  mischievous  factor  is  loss  of  uterine  support.  The  uterus 
is  normal  in  weight  and  exposed  to  no  evil  influences  from  pressure  or 
traction,  but  its  feeble  supports  even  then  are  unfit  for  their  functions,  and 
the  uterus  falls.  It  descends  to  the  second  degree,  and,  dragging  upon  the 
broad  ligaments,  their  aponeurotic  expansions  compress  the  hypogastric 
veins,  great  congestion  results,  and  at  once  a  new  influence  develops — 
increased  uterine  weight.  Now  rectal  and  vesical  tenesmus  and  pressure 
by  the  displaced  abdominal  viscera  add  another  untoward  element — force 
applied  from  above.  And  as  the  descending  uterus  everts  still  further 
the  congested,  voluminous,  and  heavy  vagina,  it  drags  the  offending  organ 
still  more  rapidly  down. 

4th.  The  reader  wearied  by  repetition  may  crave  a  respite  here,  but  he 


388  ASCENT    AND    DESCENT    OF    THE    UTERUS. 

asks  it  just  where  it  cannot  be  granted,  for  we  come  to  the  consideration 
of  the  most  frequent  and  consequently  most  important  of  all  the  influ- 
ences resulting  in  prolapsus  uteri.  Prolapse  of  the  uterus  is  sometimes  a 
primary  affection,  but  in  the  great  majority  of  cases  it  is  secondary,  pro- 
duced by  prolapse  of  the  vagina,  which  literally  drags  it  from  its  position. 
There  are  two  methods  in  which  this  occurs :  1st.  The  perineum  is  rup- 
tured, and  by  this  the  vaginal  walls  lose  the  buttress  against  which  they 
rest,  and  the  power  of  the  pubo-coccygeus  muscle  is  diminished.  2d.  A 
vagina  developed  by  utero-gestation  does  not  urtdergo  involution,  but 
remains  a  large,  voluminous,  and  heavy  bag,  the  redundant  walls  of 
which  overcome  the  resistance  of  the  perineal  body  and  prolapse,  dragging 
the  uterus  down,  either  before  or  simultaneously  with  their  escape  from 
the  vulva. 

Dr.  Duncan,  in  an  essay  read  before  the  Edinburgh  Obstetrical  Society,1 
in  1871,  maintained  that  the  perineum  had  nothing  to  do  with  the  support 
of  the  uterus,  and  that,  therefore,  laceration  of  this  part  is  not  a  cause  of 
prolapsus.  I  do  not  believe  that  the  perineum  supports  the  uterus  directly, 
nor  that  upon  the  cadaver  its  section  would  result  in  prolapsus ;  but  I 
believe  that  destruction  of  the  perineal  body  which  acts  as  a  support  to 
the  vagina  results  in  loss  of  support  to  both  its  posterior  and  anterior 
walls.  These  prolapse,  their  tissue  becomes  hypertrophied,  and  they  drag 
down  the  bladder  and  then  the  uterus.  Look  at  Fig.  5G  and  see  how 
much  support  vagina  and  bladder  obtain  from  the  perineal  body,  and  the 
results  of  its  rupture  may  be  better  appreciated.  So  long  as  the  vagina 
is  normal  in  volume  and  weight,  and  remains  within  the  pelvis  with  its 
walls  in  apposition,  it  constitutes,  by  its  ante-cervical  projection,  I  think, 
a  uterine  support.  So  soon  as  it  falls  from  the  pelvic  cavity,  becomes 
hypertrophied,  and  has  its  walls  separated,  it  not  only  loses  this  power, 
but  degenerates  into  a  uterine  tractor. 

The  same  authority  points  to  the  fact  that  many  cases  of  complete 
perineal  laceration  do  not  produce  prolapsus  uteri.  This  is  true.  Such 
laceration  is  usually  the  result  of  parturition,  and  is,  I  am  satisfied,  often 
a  cause  of  subinvolution  of  the  vagina.  If  this  condition  has  resulted,  the 
laceration  is  very  generally  followed  by  prolapsus  vagina^,  and  thus  by 
descent  of  the  uterus.  If  vaginal  involution  have  not  been  interfered 
with,  it  is  usually  not  so. 

Aran  points  out  the  fact,  that  removal  of  the  vagina  from  the  cadaver 
does  not  produce  uterine  prolapse,  and  Dr.  Duncan  declares,  "  I  have  no 
doubt  that,  if,  by  way  of  experiment,  the  perineum  was  cut  through  in  a 
healthy  woman,  no  tendency  to  prolapsus  would  be  thereby  produced." 
I  freely  accept  both  experiment  and  proposition,  but  I  cannot  agree  in  the 
deductions  based  upon  them.  "When  the  uterine  ligaments  are  strong, 
the  uterus  does  not  readily  leave  its  position.     Sometimes  traction  steadily 

1  Transactions,  vol.  ii.  p.  209. 


PATHOLOGY    OF    PROLAPSUS    UTERl.  389 

exerted  upon  the  cervix  fails  to  draw  down  the  body,  but  stretches  the 
neck  so  that  the  uterus  measures  by  the  sound  between  nix  and  seven 
inches.  Klob1  declares,  that  "relaxation  of  the  uterine  tissue  is  notice- 
able in  the  region  of  the  external  orifice,  and  consequently  in  what  was 
previously  the  vaginal  portion  and  lower  segment  of  the  cervix,  which 
part  often  assumes  a  spongy  softness.  This  relaxation  must  be  attributed 
to  the  varicose  condition  of  the  bloodvessels,  and  absorption  of  the  cervi- 
cal tissue."  This,  and  not  hypertrophy,  is  probably  the  condition  of  this 
distended  part.  In  many  cases,  before  prolapse  occurs,  the  uterus  is 
affected  by  areolar  hyperplasia,  or  the  local  atrophic  state  engendered  by 
flexion,  which  last  Dr.  Hewitt  regards  as  a  frequent  source  of  it,  and 
when  thus  weakened  it  readily  yields  to  traction.  When  the  tractile 
force  is  checked  by  reposition  of  the  uterus,  the  neck  instantly  contracts, 
and  the  length  of  the  whole  organ  greatly  diminishes. 

May  this  fact  not  explain  the  experience  of  Huguier,  who  found  only 
two  cases  of  true  prolapse  in  sixty  reported  cases,  and  of  Routh,  who  in  a 
large  experience  met  with  only  three?  It  seems  to  me  highly  probable 
that  these  investigators,  making  their  measurements  while  the  uterus  was 
prolapsed  to  the  third  degree,  concluded  that  hypertrophic  elongation  of 
the  supra-vaginal  portion  existed,  when  in  reality  this  peculiarly  elastic 
tissue,  which  was  the  consequence  and  not  the  cause  of  the  descent,  was 
the  true  pathological  condition.  Certainly  some  such  explanation  must 
account  for  the  remarkable  discrepancy  which  exists  between  the  results 
of  these  two  eminent  gynecologists  and  the  great  majority,  whose  experi- 
ence is  opposed  to  theirs. 

In  these  cases  the  force  of  traction  appears  to  expend  itself  upon  the 
most  powerful  uterine  ligaments,  those  inserted  at  the  axis  of  rotation,  the 
cervico- corporeal  junction.  They  yield,  and  the  cervix  advances  towards 
the  vulva,  but  the  uterus,  supported  though  it  is  by  factors  of  less  power, 
resists  steady  traction,  and  remains  in  place.  Legendre  attached  to  the 
cervix  uteri  of  a  cadaver,  a  weight  of  fifteen  kilogrammes,  which  was 
gradually  increased  to  fifty  during  the  period  of  an  hour,  then  diminished 
to  thirty,  and  kept  up  traction  by  that  for  two  hours.  At  the  commence- 
ment, the  uterine  canal  measured  by  the  sound  five  centimetres,  and  at 
its  conclusion  nine,  the  lengthening  being  chiefly  in  the  cervix.  In  other 
experiments,  a  less  weight  kept  in  action  for  several  days,  caused  complete 
prolapse  with  elongation  of  the  cervix  uteri. 

Since  the  appearance  of  Huguier's  essay  upon  supra-  and  infra-vaginal 
elongation  of  the  cervix  as  conditions  commonly  mistaken  for  prolapsus, 
writers  have  commonly  considered  hypertrophic  elongation  of  the  cervix 
below  the  vaginal  junction  under  this  head.  I  shall  not  do  so,  because 
the  propriety  of  such  a  course   seems  to  me  to  be  sustained  neither  by 

1  Up.  cit.,  p.  88. 


390        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

clinical  observation  nor  pathological  investigation,  and  because  true  cer- 
vical hypertrophy  will  be  elsewhere  treated  of. 

That  there  is  a  form  of  hypertrophic  elongation  of  the  cervix  uteri, 
which  occurs  below  the  cervico-vaginal  junction,  and  appears  upon  very 
superficial  examination  to  resemble  prolapsus,  or  even  produces  that  con- 
dition by  traction,  I,  of  course,  admit.  But  it  appears  to  me  erroneous  to 
regard  supra- vaginal  elongation,  which  is  marked  by  an  attenuation  of  the 
tissues  of  the  neck  and  "  a  spongy  softness,"  according  to  Klob  attributable 
to  a  "  varicose  condition  of  the  bloodvessels  and  absorption  of  the  cervical 
tissues,"  as  true  hypertrophy. 

It  is  highly  probable  that  this  condition,  the  result  of  traction,  may 
occur  during  pregnancy,  and  exist  as  a  source  of  great  annoyance  after  it. 
The  following  deductions  by  M.  Gueniot1  substantiate  this  view  : — 

"  1.  In  certain  women  there  exists  during  pregnancy,  and  occasionally 
at  the  time  of  parturition,  a  special  affection  of  the  neck  of  the  womb, 
which  generally  passes  unrecognized,  and  has  not  hitherto  been  the  subject 
of  any  description. 

"  2.  This  affection  may  be  designated  under  the  name  of  (Edematous 
Elongation  with  Prolapse  of  the  Neck,  which  indicates  the  principal  con- 
stituent traits.  Hyperemia  and  turgescence  of  the  organ,  the  arrange- 
ment of  its  cavity,  which  is  transformed  into  a  long  and  freely  patent 
canal ;  the  rapidity  with  which  these  symptoms  may  disappear,  and  the 
great  facility  with  which  they  may  be  reproduced  under  certain  circum- 
stances, are  all  so  many  fundamental  characters  of  the  affection.  Ulcera- 
tion of  the  os  tinea?,  occlusion  of  the  vagina,  a  thin  and  flaccid  condition 
of  the  uterine  walls,  are  also  almost  constant  symptoms  ;  as  are  also  cir- 
cumpelvic  pains,  a  feeling  of  general  debility,  and  variable  disturbances  in 
micturition. 

"  3.  The  causes  of  this  change  in  the  neck  of  the  uterus  are  complex ; 
they  are  derived  from  two  sources  :  certain  anatomical  dispositions  of  the 
organ,  and  various  circumstances  exerting  upon  it  a  prolonged  mechanical 
action. 

"  4.  Although  very  rare,  cedematous  elongation  with  prolapse  of  the 
neck  is,  without  doubt,  a  less  exceptional  affection  than  one  would  be  in- 
clined to  imagine.  Many  observers  have  erroneously  assimilated  it  to 
hypertrophic  elongation,  or  to  simple  prolapsus,  to  which  affections,  in 
truth,  it  presents  a  great  analogy,  but  from  which  it  is  essentially  distin- 
guished by  proper  and  very  important  characters." 

Course,  Duration,  and  Termination Prolapsus  uteri  is  unlimited  in 

its  duration,  and,  unless  relieved  by  art,  will  continue  indefinitely.  It 
impairs  the  patient's  comfort  and  capacity  for  exertion,  but  rarely  has  a 
fatal  termination,  unless  by  exciting  peritoneal  inflammation,  or  pelvic 

>  Archives  Gen.  de  MM.,  Juillet,  1872. 


SYMPTOMS    OF    PROLAPSUS.  391 

cellulitis,  as  I  have  seen  it  do  in  several  cases.  Even  in  the  chronic  form 
of  the  disease,  death  has  in  very  rare  cases  occurred  from  urinaemia,  the 
result  of  interference  with  the  ureters.  The  trigone  of  the  bladder  be- 
coming displaced  to  such  an  extent  that  the  orifices  of  the  ureters  are 
pressed  firmly  against  the  symphysis  pubis  by  the  mass  behind  it,  they 
become  obstructed  and  distended,  and  in  time  hydronephrosis  may  result. 
Virchow1  and  Kiwisch2  both  announce  this  fact.  An  interesting  instance 
of  death  thus  produced  may  be  found  in  the  twelfth  volume  of  the  Trans- 
actions of  the  London  Obstetrical  Society,  reported  by  Dr.  Phillips.  In 
a  case  of  incarcerated  uterus  occurring  in  my  own  experience,  and  which 
will  receive  further  mention  elsewhere  in  this  article,  I  was  compelled  to 
resort  to  a  degree  of  force  in  returning  the  displaced  organ,  which  at  the 
time  of  application  I  regarded  as  attended  by  extreme  danger.  Had  my 
efforts  not  succeeded,  death  would,  I  feel  sure,  have  resulted ;  for  the 
uterus  and  surrounding  parts  appeared  to  be  about  passing  into  a  state  of 
gangrene.  This  case  before  I  saw  it  had  resisted  all  the  efforts  which 
were  applied  by  three  competent  physicians.  After  forcible  replacement, 
the  entire  lining  membrane  of  the  vagina  sloughed,  and  the  patient  narrowly 
escaped  death  from  peritonitis,  which  was  excited  and  ran  a  violent  course. 
Forcible  taxis  was  resorted  to,  with  a  conviction  on  the  part  of  the  attend- 
ing physicians  and  myself,  that  the  issue  involved  either  restitution  of  the 
uterus  or  death. 

Symptoms. — The  symptoms  of  prolapsus  are  dependent  upon  two  re- 
sults growing  out  of  the  displacement  :  the  mechanical  interference  of  the 
womb  with  surrounding  parts,  and  alteration  induced  in  its  circulation 
and  tissue  by  reason  of  its  abnormal  position.  The  uterus  may  remain 
even  in  the  third  degree  of  descent  without  any  marked  symptoms,  but 
generally  congestion,  areolar  hyperplasia,  and  granular  degeneration  occur, 
which  render  it  sensitive  and  intolerant  of  pressure  or  friction.  At  the 
same  time,  by  dragging  upon  the  bladder,  rectum,  and  all  the  pelvic 
areolar  tissue  and  fascia?,  and  by  protruding  between  the  labia,  it  produces 
discomfort  and  often  impedes  locomotion  to  a  great  extent.  The  most 
prominent  of  the  symptoms  thus  created  are  the  following : — 

Sensation  of  dragging  and  weight  in  the  pelvis  ; 

Rectal  and  vesical  irritation  ; 

Pain  in  back  and  loins  ; 

Great  fatigue  from  walking  ; 

Inability  to  lift  weights  ; 

Leucorrhoea  and  other  signs  of  congestion. 
It  is  a  very  singular  and   striking  fact,  that  in  prolapsus,  even  of  the 
third  degree,  there   is  very  commonly  no  menstrual  disorder,  and  equally 
remarkable  that  sterility  does   not   ordinarily  exist.     These   immunities 

»  Trans.  Obstet.  Soc.  of  Berlin,  1847.  2  Clinical  Lectures. 


392        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

are  probably  dependent  upon  the  facts  that  the  uterine  catarrh  which 
usually  exists  is  rather  the  result  of  a  passive  congestion  of  the  endome- 
trium than  of  true  inflammation,  and  that  the  axis  of  the  organ,  although 
altered  in  direction,  is  not  bent  upon  itself  so  that  an  obstruction  in  it  is 
created. 

Physical  Signs All  the  symptoms  detailed  will  only  excite  suspicion 

and  prompt  an  examination  which  will  fully  elucidate  the  case.  Should 
the  affection  exist  only  in  the  first  degree,  the  finger  passed  up  the  vagina 
will  meet  with  the  os  low  down  in  the  pelvis  and  pressing  upon  its  floor. 
As  it  is  slid  upward  in  front  of  the  cervix  and  along  the  base  of  the  bladder, 
the  resisting  anterior  wall  of  the  uterus  will  be  clearly  distinguished,  and 
it  may  be  found  that  anteversion  or  anteflexion  exists,  complicating  pro- 
lapsus. 

If  the  second  degree  have  been  reached,  the  os  will  be  found  at  the 
ostium  vaginae,  prevented  from  escaping  only  by  the  resistance  of  the 
sphincteric  muscles,  and  the  body,  instead  of  lying  forwards,  will  be  to 
some  extent  retroverted.  To  determine  the  degree  of  prolapsus,  more 
especially  in  this  stage,  the  patient  should  be  examined  standing. 

Sight  and  touch  will  combine  in  making  a  diagnosis  in  the  third  degree 
of*  prolapse  rapid  and  easy,  but  even  here  I  have  known  very  grievous 
mistakes  committed.  The  apparent  ease  of  the  diagnosis  sometimes  causes 
error  by  inducing  neglect  of  that  caution  and  watchfulness  which,  even 
in  the  simplest  cases  of  disease,  constitute  the  only  safeguard  of  the  phy- 
sician. 

One  very  curious  phenomenon  which  in  the  physical  investigation  of 
these  cases  must  have  struck  every  practitioner  is  this :  the  uterus  being 
procident  and  a  sound  introduced,  it  passes  up  for  the  distance  of  five  or 
six  inches.  The  organ  now  being  replaced,  and  again  examined  by  the 
sound,  it  is  found  to  measure  only  three  or  four,  and  this  experiment  may 
be  repeated  any  number  of  times  with  the  same  result.  The  explanation 
of  this  fact  is  given  in  connection  with  the  subject  of  pathology. 

Differentiation In  any  of  its  varieties  prolapsus  uteri  may  be  con- 
founded with  fibrous  polypus,  inversion  of  the  uterus,  and  hypertrophic 
elongation  of  the  neck,  from  all  of  which,  however,  it  is  readily  distin- 
guished if  the  practitioner  be  awake  to  the  possibility  of  error.  From 
tin.-  first  it  is  known  by  the  presence  of  the  os  and  cervix,  and  the  general 
shape  of  the  mass.  From  the  second,  by  the  presence  of  the  os  and 
cervix,  and  absence  of  the  signs  of  inversion.  The  third  will  readily  be 
recognized  by  the  great  length  of  the  cervix,  the  impossibility  of  replacing 
the  supposed  prolapsed  organ,  and  the  great  depth  of  the  uterus  discovered 
by  the  uterine  probe,  after  it  has  been  restored  to  the  pelvis. 

Prognosis In  most  cases  a   great  deal  of  relief  can   be  effected  by 

medical  and  minor  surgical  means.  In  a  few  in  which  the  displacement  is 
secondary  to  the  existence  of  a  large  abdominal  or  perhaps  uterine  tumor, 


COMPLICATIONS    OF    PROLAPSUS.  393 

nothing  can  be  done  either  for  relief  or  cure.  In  many  in  which  descent 
of  the  uterus  is  secondary,  due  to  traction  upon  it  by  the  prolapsed  vagina, 
bladder,  and  rectum,  cure  can  be  effected,  even  where  the  third  degree 
lias  been  reached,  by  surgical  procedures  appropriate  to  the  cure  of  the 
primary  displacements  which  produce  traction  upon  the  uterus. 

In  cases  existing  only  in  the  first  and  even  the  second  degree  cure  may, 
in  favorable  cases,  be  accomplished  by  mere  removal  of  the  causes  which 
are  gradually  depressing  the  uterus. 

Complications. — Prolapsus  of  the  uterus  in  its  first  and  second  degrees, 
and  still  more  frequently  in  its  third,  produces  the  following  complications  : — 

Congestion  of  the  uterus  and  its  appendages  ; 

Endometritis  and  Fallopian  salpingitis  ; 

Hyperplasia  of  uterus  ; 

Hypertrophic  elongation  of  the  cervix ; 

Cystocele  ; 

Rectocele. 
As  soon  as  the  uterus  descends  into  complete  prolapse,  and  to  a  less 
extent  when  it  has  reached  only  the  first  and  second  degrees,  its  tissue 
becomes  congested,  and  appears  swollen,  cedematous,  soft,  and  relaxed. 
In  time  this  passive  hyperemia  induces  hyperplasia,  which  especially 
affects  the  connective  tissue.  As  a  consequence  the  uterus  is  enlarged, 
and  increased  in  weight  and  capacity.  Not  only  do  congestion  and  hyper- 
plasia affect  the  parenchyma  of  the  uterus  ;  the  mucous  membrane  and' 
submucous  tissue  are  likewise  disordered,  and  endometritis  is  an  almost 
invariable  consequence  of  prolapse.  It  has  been  already  stated  that  pecu- 
liar changes  occur  in  the  cervix.  This  part  becomes  particularly  soft  and 
relaxed  ;  its  vessels  become  varicose,  and  the  muscular  tissue  is  often 
absorbed  in  great  degree. 

In  consequence  of  these  secondary  morbid  states  we  generally  have  as 
concomitant  symptoms,  leucorrhoea,  dilatation  and  eversion  of  the  cervix, 
disorders  of  the  bladder  and  rectum,  and  sometimes  cystitis.  Eversion  of 
the  cervix  is  too  important  a  feature  of  the  condition  to  be  passed  by  with- 
out special  mention.  As  the  uterus  descends  it  inverts  the  vagina.  This, 
by  its  cervical  attachment,  which  now  becomes  depressed  to  a  point  far 
below  its  upper  portion,  makes  constant  traction  upon  the  os  externum ; 
the  principle  being  the  same  as  that  by  which  the  colpeurynter  is  made  to 
dilate  this  part  for  the  establishing  or  expediting  the  first  stage  of  labor. 
As  this  action  is  prolonged  and  increased  by  further  descent  of  the  uterus 
and  inversion  of  the  vagina,  the  cervical  canal  is  rolled  out,  so  as  to  be- 
come completely  everted,  and  the  os  internum  becomes  literally  the  ex- 
ternal and  only  os  uteri,  the  real  os  externum  having  disappeared  by 
expansion. 

Dislocation  of  the  bladder  is  accomplished  by  uterine  descent  to  such 
an  extent   that  if  a  catheter  be   introduced  it  will  pass  downwards  and 


394        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

backwards.  This  complication  is  important,  for  not  only  do  traction  and 
dislocation  tend  to  the  production  of  cystitis ;  it  is  further  induced  by 
reflex  irritation  and  by  decomposition  of  urine  occurring  from  retention, 
after  urination,  in  the  pocket  formed  by  the  inverted  wall  of  the  bladder. 
By  a  similar  process  prolapse  of  the  anterior  wall  of  the  rectum  occurs, 
and  results  in  fecal  impaction  at  this  point. 

Sudden  or  Acute  Prolapsus  may  come  on  from  any  great  effort,  a  fall, 
or  violent  contraction  of  the  abdominal  muscles,  acting  upon  a  uterus 
which  is  enlarged  by  hyperplasia,  subinvolution,  pregnancy,  or  tumors.  It 
may  even  occur  to  a  uterus  normal  in  size  and  consistency.  In  an  instant 
the  patient  feels  that  something  has  given  way  within  her,  becomes  pros- 
trate and  much  alarmed,  and  suffers  pain  of  an  expulsive  character,  as  if 
desirous  of  forcing  something  from  the  pelvis.  I  have  twice  seen  it  occur 
within  a  fortnight  after  delivery  from  sudden  and  violent  muscular  effort: 
and  once  in  a  nulliparous  girl  of  nineteen  years,  in  consequence  of  a  violent 
muscular  effort  made  to  lift  a  heavy  weight,  the  cervix  was  driven  out  of 
the  vulva,  the  body  being  arrested  by  the  sphincter  vaginas  and  perineal 
septum.  The  last  patient  I  saw  a  year  after  the  accident.  She  had 
suffered  intensely  from  the  displacement,  but  from  false  modesty  had  never 
told  of  it.  I  discovered  distinct  traces  of  the  hymen,  which  I  had  every 
reason,  both  physical  and  moral,  to  believe  had  not  been  ruptured  by 
sexual  congress. 

In  such  a  case  as  this  it  appears  to  me  highly  probable  that  the  utero- 
sacral  ligaments  are  ruptured.  This  supposition,  the  difficulty  of  proving 
which  by  necropsy  is  apparent,  may  have  attracted  attention,  but  the  only 
allusion  to  it  which  I  have  met  with  is  the  following  from  Courty,  who, 
in  speaking  of  the  utero-sacral  ligaments,  says,  "  if  they  are  stretched  or 
broken,  the  entire  organ  falls." 

In  acute  prolapsus,  should  reduction  not  be  affected  at  once,  violent 
pain  will  be  felt  over  the  sacrum  and  groins,  and  the  degree  of  traction 
exerted  upon  the  pelvic  peritoneum  may  result  in  dangerous  inflammation. 

Treatment The  first  indication  as  to  treatment  is  to  return  the  dis- 
placed organ  to  its  normal  position  ;  the  second,  to  keep  it  there. 

Methods  of  Replacing  the  Uterus. — In  general  no  difficulty  will  attend 
the  performance  of  the  first  indication,  but  in  some  cases  careful  and 
intelligent  taxis  will  be  necessary.  The  best  method  for  applying  this  is 
the  following:  the  patient,  after  thorough  evacuation  of  the  bladder  and 
rectum,  if  this  be  possible,  should  be  placed  in  the  genu-pectoral  position,  in 
order  to  cause  gravitation  of  the  pelvic  and  abdominal  viscera  towards  the 
diaphragm.  She  should  not  kneel  upon  a  soft  or  yielding  bed,  into  which 
the  knees  would  sink,  but  upon  the  floor  or  a  table,  for  the  object  of  the 
posture  is  to  elevate  the  buttocks  and  depress  the  thorax  as  much  as  pos- 
sible. Ten  or  fifteen  minutes  should  then  be  allowed  to  elapse  before  any 
eflbrts  are  made  at  reduction.     In  this  time  the  intense  congestion  which 


METHODS  OF  SUSTAINING  THE  UTERUS.        395 

exists  in  the  pelvic  viscera  will  greatly  diminish.  The  operator  then 
taking  the  cervix  into  the  grasp  of  his  index,  middle,  and  ring  fingers, 
pushes  the  uterus  firmly  and  forcibly  upwards  in  coincidence  with  tlie 
axis  of  the  inferior  strait.  "While  the  right  hand  is  thus  employed, 
the  left  rests  upon  the  back  of  the  patient  and  steadies  her  body.  No 
sudden  or  violent  force  is  exerted,  but  by  steady  pressure,  kept  up,  if 
necessary,  for  fifteen,  twenty,  or  thirty  minutes,  the  uterus  is  restored  to 
its  place. 

Few  cases  will  resist  this  kind  of  effort  at  reduction,  although  some  may 
do  so.  For  example,  I  have  already  referred  to  a  case  in  which  an  in- 
carcerated uterus,  which  appeared  upon  the  point  of  becoming  gangrenous, 
could  not  be  reduced  by  the  method  described,  and  in  which,  as  no  time 
was  to  be  lost,  I  produced  complete  anaesthesia,  and  then,  taking  the  organ 
firmly  in  the  extremities  of  the  thumb  and  three  fingers,  I  carried  it  by 
main  force  into  position. 

Methods  of  Sustaining  the  Uterus. — Before  pursuing  any  special  course 
of  treatment  for  this  end,  the  practitioner  should  endeavor  to  discover  the 
cause  of  the  descent.  If  it  be  due  to  increase  in  the  weight  of  the 
uterus,  or  to  pressure  exerted  upon  it  from  above,  it  is  evident  that 
the  indication  will  be  very  different  from  what  it  would  be  if  the  cause 
were  traction  by  a  prolapsed  vagina.  Unfortunately,  however,  after  the 
disease  has  existed  for  some  time,  it  is  often  impossible  to  fix  definitely 
upon  the  cause  ;  for  even  if  it  were  originally  increase  of  uterine  weight, 
the  lengthy  inversion  of  the  vagina,  and  stretching  of  the  uterine  ligaments 
involved  in  its  descent,  will  have  destroyed  all  power  in  these  parts. 

As  far  as  possible,  however,  the  original  cause  should  be  ascertained, 
and  if  it  be  properly  sought  for  it  will,  in  a  number  of  cases,  be  discovered. 
For  example,  suppose  that  there  be  no  excessive  enlargement  or  prolapse 
of  the  vagina,  no  evidence  of  excessive  downward  pressure,  and  yet  the 
uterus  lies  upon  the  pelvic  floor.  Strength  should  be  given  to  its  normal 
supports. 

Suppose,  on  the  other  hand,  that  the  vagina  be  found  to  be  in  its  normal 
state,  and  the  prolapsed  uterus  to  be  very  heavy,  weighing,  perhaps,  three 
times  what  it  should.  This  increase  of  weight  should  receive  especial 
attention. 

If,  again,  the  insignificant,  atrophied  uterus  of  an  old  woman  of  seventy 
be  prolapsed  into  a  large,  flabby,  non-contractile  vagina,  traction  by  this 
vagina  may  safely  be  accredited  with  the  uterine  displacement. 

Lastly,  if  the  common  coincidence  of  rupture  of  the  perineum,  with 
subinvolution,  and  prolapse  of  the  vagina  and  uterus  be  encountered,  it 
may  be  assumed  that  increase  of  uterine  weight,  loss  of  support,  and  trac- 
tion, have  all  combined  to  bring  about  the  issue. 

It  should  be  the  care  of  the  physician  to  keep  every  one  of  the  indica- 
tions suggested  by  these  factors  in  mind ;  and  in  every  case  attend  first  to 


396        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

that  which  concerns  the  primary  and  most  important ;  afterwards,  to  those 
which  are  secondary  and  created  by  the  displacement  itself. 

A  very  important  question  offers  itself  for  consideration  here  :  Is  it  pos- 
sible to  give  relief  in  an  aggravated  case  of  prolapse  in  the  third  degree 
without  resort  to  operative  procedure  ?  The  position  has  of  late  been 
taken  by  high  authority  that  surgery  must  always  be  invoked  as  our  final 
resort  in  such  cases,  and  that  less  radical  treatment  should  be  looked  upon 
as  palliative  and  in  great  degree  preparatory.  This  I  regard  as  a  doc- 
trine calculated  to  do  great  harm,  and  one  which  entirely  misrepresents  the 
true  requirements  of  the  subject.  I  should  state  the  matter  thus :  In  a 
very  large  majority  of  cases  of  prolapse  of  the  uterus,  whether  in  the  first, 
the  second,  or  the  third  degree,  relief  may  be  obtained  without  resort  to 
operation ;  in  a  certain  number  of  cases  where  traction  by  the  prolapsed 
vagina,  rectum,  or  bladder  is  the  cause  of  the  uterine  displacement,  it 
should  be  our  chief  resource.  Now  it  may  be  said  in  reply  to  this  that 
even  if  such  traction  was  not  a  primary  factor  in  the  displacement,  it  is 
always  a  secondary  one,  and,  like  a  great  many  theoretical  observations, 
this  will  carry  weight.  But  it  is  not  really  a  valid  argument  at  the  bed- 
side for  him  who  studies  these  cases  from  a  scientific  standpoint,  however 
powerful  it  may  be  in  the  mind  of  the  empirical  gynecologist.  If  the 
perineum  have  lost  all  power,  and  a  loose,  flabby  condition  exist  in  the 
vagina  from  subinvolution  or  hyperplasia  the  consequence  of  prolonged 
congestion,  and  the  resulting  vaginal,  vesical,  and  rectal  prolapse  has 
dragged  the  uterus  down,  operation  merely  fulfils  the  important  indication 
of  removing  the  cause  of  the  trouble,  and  logically  presents  itself  as  an 
important  resource.  If,  on  the  other  hand,  a  heavy  uterus  presses  down 
of  its  own  weight,  or  a  normal  one  is  forced  down  by  pressure  from  above, 
closing  the  perineum,  or  contracting  the  vagina  by  colporrhaphy,  is  illogi- 
cal, unnecessary,  and  empirical.  I  would  conclude  this  part  of  the  subject 
by  repeating,  that  operative  procedure  for  uterine  prolapse  should  be  only 
exceptionally  resorted  to,  and  then  to  fulfil  an  indication,  not  to  comply 
with  a  dogmatic  rule. 

I  have  at  this  moment  under  observation  a  number  of  cases  in  which 
entire  relief  to  complete  prolapse  has  been  afforded  by  means  which  will 
soon  be  mentioned  here.  So  complete  is  this  that  the  patients  thus  relieved 
would  not  listen  to  the  proposal  of  operation.  It  is  true,  that  complete 
cure  has  not  been  effected,  but  complete  relief  has.  If  the  operative  pro- 
cedures for  such  cases  were  simple,  entirely  free  from  danger,  and  certain 
as  to  result,  a  universal  resort  to  them  would  be  indicated ;  but  they  are 
not  so.  I  would  not  willingly  appear  to  oppose  operation  in  these  cases, 
for  I  favor  it  and  constantly  practise  it.  I  merely  urge  the  application  to 
them  of  the  ordinary  rules  which  govern  the  scientific  surgeon  elsewhere. 

I  will  now  consider  in  order  the  methods  most  appropriate  for  resisting 
each  of  the  pathological  conditions  which  result  in  uterine  prolapse. 


METHODS  OF  SUSTAINING  THE  UTERUS. 


.397 


The  means  adapted  to  prevention  of  pressure  from  above  are — 

Removing  weight  of  clothing  by  use  of  skirt-supporters  ; 

Removing  weight  of  intestines  by  prohibition  of  tight  clothing,  use  of 
sin  abdominal  supporter,  and  avoidance  of  injurious  muscular  efforts; 

Preventing  accumulation  of  urine  and  feces. 

The  skirt-supporter  is  merely  a  pair  of  suspenders  that  may  be  contrived 
by  any  woman  of  ordinary  ingenuity,  and  which  enables  the  patient  to 
carry  the  whole  weight  of  the  under-garments  upon  the  shoulders.  A 
representation  of  a  very  good  one  will  be  found  in  Fig.  141.  Or  the 
skirts  may  be  affixed  to  a  waist,  which  replaces  the  corset,  by  buttons,  as 
shown  in  Fi<r.  112. 


Fig.  141. 


Fig.  142. 


Skirt-supporter. 


Waist  with  buttons  for  support  of  skirts. 


There  are  many  varieties  of  the  abdominal  supporter,  some  of  which, 
unfortunately,  are  so  constructed  as  to  do  absolute  harm.  Should  com- 
pression be  exerted  by  them  upon  the  abdomen  above  the  navel,  it  will 
tend  to  increase  pressure  upon  the  uterus,  or  at  least  to  annul  all  the 
benefit  of  that  exerted  below  this  point.  The  principle  upon  which  these 
supporters  should  act  is  this — they  should  do  just  what  the  patient's  hands 
do  when  she  places  them  above  the  pubes,  and  lifts  the  abdominal  viscera. 
Some  of  them  are  composed  simply  of  bands  of  thick  cloth,  others  are 
pads  or  disks  of  horn  or  metal,  with  encircling  bands  like  those  of  the 
hernial  truss.  The  physician  may  choose  intelligently,  if  he  only  bears 
in  mind  what  it  is  that  he  desires  to  accomplish  by  them. 

During  the  continuance  of  treatment  the  patient  should  be  limited  as  to 
exercise  and  confined  to  bed  during  menstrual  epochs,  when  the  uterus  is 
known  to  be  heavier  than  at  other  times.  Should  the  accident  have 
immediately  followed  parturition,  she  should  be  kept  in  the  recumbent 
posture  to  favor  the  accomplishment  of  involution. 


398        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

Means  adapted  to  diminution  of  uterine  weight  are — 

Removing  polypi,  tumors,  etc.,  by  operation  ; 

Removing  uterine  inflammation,  hypertrophy,  and  congestion,  by  appro- 
priate treatment ; 

Amputation  of  the  neck  of  the  womb ; 

Repairing  laceration  of  the  neck. 

Sometimes,  by  applying  appropriate  treatment  to  an  enlarged  cervix, 
the  uterus  is  in  time  so  much  lightened  by  cure  of  attendant  hypenemia 
that  relief  is  effected,  but  in  other  cases  the  hypenemia  is  so  persistent 
and  rebellious  that  these  means  fail,  and  resort  must  be  had  to  more 
powerful  ones.  A  lacerated  cervix  will  often  prove  a  focus  of  irritation, 
and  thus  a  cause  of  uterine  congestion  and  hyperplasia,  which  may  result 
in  descent  of  the  uterus.  Under  these  circumstances  closure  of  the  lacera- 
tion will  often  effect  a  complete  cure,  and  it  should  without  delay  be  per- 
formed. 

In  some  cases,  even  when  parturition  has  never  occurred,  hypertrophy 
of  the  cervix  occurs  and  proves  "a  cause  of  prolapsus.  For  this,  resort  has 
been  had  to  amputation  of  the  neck.  M.  Huguier,  of  Paris,  was,  in  1848, 
the  first  to  perform  this  operation  for  prolapsus,  though  it  has  long  been 
resorted  to  for  cancer.  Since  that  time  it  has  been  performed  by  many 
others,  after  methods  which  will  be  described  in  a  chapter  devoted  to  the 
operation.  It  must  not  be  supposed  that  the  mere  removal  of  superabun- 
dant tissue  is  relied  upon  for  the  diminution  of  uterine  weight.  It  is 
rather  the  derivative  and  alterative  influences  set  up  by  amputation  of 
which  the  surgeon  endeavors  to  avail  himself. 

Means  for  strengthening  or  supplementing  uterine  supports: — 
The  recumbent  posture  ; 
Local  astringents  and  tonics  ; 
General  tonics ; 

Exercising  the  retentive  powers  of  the  abdomen  ; 
Pessaries. 

T7te  recumbent  posture,  persistently  persevered  in,  accomplishes  a  great 
deal  of  good  in  cases  of  prolapsus  in  the  first,  and  sometimes  even  in  the 
second  degree.  The  buttocks  being  elevated,  the  uterus  retreats  from  the 
pelvis,  and  its  supports  are  left  entirely  at  rest.  Opportunity  is  thus 
afforded  the  weakened  tissues  to  contract,  to  gain  tone  and  strength,  and 
in  time  to  resume  their  functions.  The  results  of  posture  may  be  mate- 
rially increased  by  simultaneous  employment  of  the  following  agents. 

Astringents  and  Tonics. — By  these  means  the  pelvic  tissues  may  be 
made  to  sustain  the  uterus  for  a  time,  and  thus  by  keeping  it  out  of  dan- 
ger of  congestion  from  interference  with  circulation,  opportunity  is  given 
for  removal  of  engorgement  or  slight  hypertrophy. 

The  astringents  most  commonly  employed  are  tannin,  alum,  persulphate 


ASTRINGENTS    AND    TONICS.  ?>99 

of  iron,  and  the  bark  of  the  white  oak.  They  may  he  injected  into  the 
vagina  in  solution  or  infusion,  by  means  of  the  ordinary  syringe.  A  very 
excellent  astringent  under  these  circumstances  is  the  infusion  of  the 
sumach  berry,  which  grows  commonly  by  our  roadsides  throughout  the 
country. 

Tonics  may  be  locally  applied  by  the  use  of  cold  hip-baths,  douches, 
sea-baths,  and  by  copious  vaginal  injections  of  cold  water,  salt  and  water, 
or  sea-water. 

General  tonics,  mineral  and  vegetable,  should  be  employed.  Among 
these,  ergot,  strychnia,  and  iron  may  be  specially  mentioned.  Sea-bathing 
is  peculiarly  beneficial  for  this  purpose,  for  it  not  only  acts  locally,  but 
improves  the  tone  of  the  whole  system.  In  speaking  generally  of  the 
influences  which  sustain  the  uterus,  the  peculiar  retentive  power  of  the 
abdomen  has  been  mentioned  very  fully.  Habits  of  life,  with  reference 
to  exercise,  dress,  etc.,  exert  a  marked  influence  over  this  power.  The 
woman  who  rarely  exercises  so  as  to  call  for  full  expansion  of  the  lungs, 
gradually  diminishes  her  breathing  power,  and  in  the  end  suffers  from 
atony  of  the  thoracic  muscles.  This  renders  diaphragmatic  action  feeble; 
the  alternate  rise  and  fall  of  the  abdominal  viscera  is  lessened  ;  they  settle 
down  upon  the  pelvic  viscera;  and  the  abdominal  muscles  lose  their  power 
and  activity.  This  result  is  produced  not  only  by  a  life  of  inactivity, 
which  enfeebles  the  muscles  which  accomplish  thoracic  and  abdominal 
respiration  by  want  of  use,  and  thus  indirectly  lessens  diaphragmatic 
action ;  any  influence  which  directly  interferes  with  the  piston-like 
action  of  the  diaphragm,  or  indirectly  enfeebles  by  prolonged  pressure  the 
thoracic  and  abdominal  muscles,  tends  to  overcome  this  important  function 
of  the  abdomen  in  supporting  and  keeping  the  uterus  in  good  circulatory 
condition.  Should  any  one  doubt  this,  let  him  examine  with  Sims's 
speculum  several  tightly-laced  women,  who,  since  childhood,  have  done 
all  that  art  could  do  to  annihilate  this  sustaining  power  of  the>abdomen; 
and  then  the  same  number  of  women  undeformed  by  the  pernicious  habit. 
Let  him  even  examine  the  same  woman  with  and  then  without  corsets, 
and  he  cannot  fail  to  recognize  the  slight  uterine  movement  in  the  one 
case,  and  the  active,  vigorous  rise  and  fall  in  the  other.  The  influence  of 
constriction  at  the  waist  will  be  readily  appreciated  by  reference  to  Figs. 
143  and  144. 

As  the  retentive  power  of  the  abdomen  is  destroyed  by  pernicious  habits, 
it  may  with  perseverance  and  judicious  efforts  be  restored,  and  the  import- 
ance of  striving  to  accomplish  its  restoration  in  all  cases  of  uterine  dis- 
placement cannot  be  too  strongly  insisted  on.  This  should  be  done  first 
by  freeing  the  trunk  from  all  constriction  and  weight ;  second,  by  causing 
free  action  of  the  diaphragm  by  general  exercises  which  cause  this  muscle 
to  work  vigorously ;  and,  third,  by  the  practice  of  special  exercises  adapted 


400 


ASCENT  AND  DESCENT  OF  THE  UTERUS. 


to  development  of  the  thoracic  and  abdominal  muscles.  As  excellent 
general  exercises  may  be  instanced,  rowing  in  a  light  boat  or  upon  a 
rowing  machine,1  practising  the  "  lift  cure,"  the  use  of  Goodyear's  "  par- 
lor gymnasium,"  or  calisthenics.    Walking  and  riding,  either  in  a  vehicle 


Fig.  143. 


Fig.  144. 


O 


The  action  of  the  diaphragm,  the 
parts  in  normal  condition. 


The  action  of  the  diaphragm,  the  parts  deformed 
by  tight  and  heavy  clothing. 


or  on  horseback,  are  excellent  in  their  results  upon  the  general  health, 
but  they  fail  utterly  in  fulfilling  the  special  indication  required.  They 
improve  nutrition  and  strengthen  the  muscles  of  the  lower  extremities, 
but  not  those  of  the  upper  portion  of  the  trunk.  Their  substitution 
therefore  for  those  just  mentioned  is  an  error.  They  may  add  to  the 
general  good  accomplished,  but  do  not  develop  either  the  lost  function  or 
the  muscles  which  should  perform  it. 

There  are  also  particular  exercises  adapted  to  the  especial  develop- 
ment of  the  abdominal  muscles,  at  the  same  time  that  they  excite  an  ex- 
aggerated action  on  the  part  of  the.  diaphragm,  and  tend  by  that  and  by 
gravitation  to  raise  the  pelvic  viscera.  For  a  full  exposition  of  this 
subject  I  would  refer  the  reader  to  a  work  by  Dr.  George  H.  Taylor.2 
His  directions  for  the  special  fulfilment  of  this  indication  I  give  in  his 
own  words.  "The  patient  lies  back  downward  on  a  horizontal  couch, 
with  the  hands  strongly  clasped  over  the  head  and  pressing  on  its  crown  ; 
t lie  feet  drawn  up  so  that  the  heels  are  in  close  contact  with  the  trunk, 
the  soles  of  the  feet  resting  on  the  couch,  the  knee's  and  thighs  being 
strongly  flexed.     By  a  moderate  effort  the  patient  raises  the  hips  as  high 


1  Implements  for  these  exercises  are  on  sale  in  all  our  large  cities. 
*  Dis.  of  Women,  Maclean,  N.  Y.,  1871. 


PESSARIES.  401 

as  she  can,  or  till  the  thighs  and  trunk  form  a  straight  line,  the  shoulders 
and  the  feet  only  resting  on  the  couch  ;  in  this  position  the  trunk  must 
for  a  few  moments  be  sustained.  The  hips  and  trunk  are  now  allowed 
slowly  to  fall  back  to  the  commencing  position  on  the  couch.  This  action 
may  be  repeated  a  dozen  or  more  times,  a  few  moments  of  rest  inter- 
vening." 

Another  exercise  is  this:  "The  invalid  lies  on  a  horizontal  couch  with 
face  downward,  the  elbows  resting  firmly  on  the  couch,  the  arms  perpen- 
dicular and  supporting  the  upper  portion  of  the  trunk,  the  ankles  strongly 
flexed,  the  toes,  like  the  elbows,  resting  firmly  on  the  couch.  By  a  strong 
effort  all  the  muscles  of  the  anterior  portion,  that  is,  the  under  side  of  the 
body,  are  caused  to  contract,  the  knees  are  straightened,  the  hips  and 
whole  body  raised  from  the  couch,  and  made  to  form  a  horizontal  line, 
touching  the  couch  at  no  point  but  the  elbows  and  toes." 

Still  another  is  the  following  :  "  Two  stools  or  chairs  are  placed  so  far 
asunder  that  the  patient,  in  lying  face  downward  across  them,  will  be  sup- 
ported by  the  chest  resting  upon  one  and  the  legs  upon  the  other.  While 
'  thus  lying  the  abdomen  is  unsupported  and  consequently  gravitates  towards 
the  ground,  causing  retraction  of  the  generative  intestine.  In  this  posi- 
tion, the  patient  must  endeavor  to  maintain  her  body  in  a  straight  line,  in 
opposition  to  the  force  of  gravity  acting  on  its  central  portion." 

Pessaries. — The  plan  of  supporting  the  prolapsed  uterus,  vagina,  bladder, 
and  rectum  by  mechanical  contrivances  which  supplement  the  enfeebled 
natural  supports  constitutes  a  method  of  great  value,  and  one  which  should 
never  be  cast  aside.  In  a  great  many  cases,  objections,  or  advanced  age 
on  the  part  of  the  patient,  want  of  skill  on  that  of  the  physician,  and  the 
uncertainty  as  to  result  which  attaches  to  all  surgical  procedures  for  the 
cure  of  prolapse,  render  a  resort  to  a  method  which  relieves  very  greatly, 
during  even  a  long  lifetime,  one  which  is  dictated  by  prudence  and  good 
sense.  To  support  four  organs,  the  vagina,  uterus,  bladder,  and  rectum, 
which  are,  and  have  been  lor  a  long  time,  prolapsed,  by  an  artificial  me- 
chanical means,  frequently  taxes  the  skill  of  the  ablest  gynecologist,  and 
sometimes  utterly  defeats  his  best  attempts.  Let  the  general  practitioner 
bear  this  undeniable  fact  in  mind,  and  not  become  discouraged  by  diffi- 
culties, nor  disheartened  by  repeated  fruitless  efforts.  Let  such  a  one 
who  reads  this  believe  too  the  assertion  which  I  here  make,  that  I  advise 
no  instrument  merely  because  it  has  been  generally  accepted,  and  that  I 
limit  myself  to  the  mention  of  those  only  which  I  daily  employ  in  practice 
with  good  results. 

In  employing  pessaries  for  all  the  varieties  of  prolapsus  of  the  pelvic 
organs,  the  desideratum  is  an  instrument  which  will  not  distend  the 
vagina,  at  the  same  time  that  it  will  support  the  uterus.  Such  instru- 
ments as  sustain  the  vagina  without  distending  it,  and  thus  allow  it  to 
regain  something  of  its  former  tone  and  elasticity,  are  those  which  should 
2G 


402        ASCENT  AND  DESCENT  OF  THE  UTERUS. 

be,  as  far  as  possible,  selected.  The  great  functions  which,  in  the  majority 
of  cases,  are  required  of  a  pessary  in  prolapsus  are  these :  first,  to  supple- 
ment the  action  of  the  utero-sacral  ligaments,  the  chief  factors  in  sustain- 
ing the  uterus ;  second,  to  keep  the  vagina,  bladder,  and  rectum  in  place, 
so  as  to  prevent  them  from  perpetuating  the  uterine  displacement  by 
traction. 

I  have  already  said,  that  he  who  treats  this  condition,  in  any  of  its 
varieties,  by  replacement  and  support  by  a  pessary,  must  frequently  meet 
with  insuccess.  Is  it  not  illogical  to  suppose  that  by  any  mechanical 
contrivance,  heavy,  congested,  and  prolapsed  organs,  often  four  in  number, 
very  generally  three,  can  be,  without  preparation  or  the  use  of  allied  means, 
kept  at  once  in  normal  position  ?  Yet  such  a  result  is  often  anticipated. 
Before  resorting  to  a  pessary  at  all,  it  is  a  good  plan  to  keep  the  patient 
in  the  recumbent  posture  for  a  few  days,  or,  if  possible,  a  week,  with  the 
foot  of  the  bedstead  elevated  twelve  inches,  for  the  purpose  of  allowing  con- 
gestion to  pass  off.  During  this  time  mild  cathartics  should  be  given  to 
further  this  end  by  removal  of  fecal  matter  and  stimulation  of  hepatic 
circulation,  and  the  vagina  should  be  systematically  and  copiously  irrigated 
with  astringent  fluids  to  harden  its  tissues  in  preparation  for  a  pessary,  to 
effect  support  of  the  uterus,  bladder,  and  rectum  by  a  re-establishment  of 
its  sustaining  power,  and  to  cause  contraction  in  its  distended  superficial 
bloodvessels.  This  time  is  not  wasted,  for  the  case  is  sure  to  be  a  lengthy 
one,  and  at  the  end  of  it,  the  patient  is  much  better  able  to  begin  treat- 
ment of  a  mechanical  kind  without  meeting  with  mishaps,  which,  in  the 
commencement,  dishearten  and  discourage  her.  Nowhere  is  the  state- 
ment more  true  than  here,  that  a  good  beginning  advances  us  half  way  to 
success. 

The  patient  having  risen,  all  of  these  means,  except  recumbency,  should 
be  continued  throughout  treatment,  and  others  which  are  adjuvants  to  the 
pessary  should  be  adopted,  as,  for  example,  removal  of  weight  of  clothing  ; 
avoidance  of  deleterious  muscular  efforts,  long  standing,  and  constrained 
postures  ;  diminution  of  weight  of  uterus  ;  development  of  retentive  power 
of  the  abdomen  ;  and  others  which  have  been  already  enumerated.  Having 
attended  to  all  these  points,  the  pessary  presents  itself  as  a  valuable  re- 
source by  which  to  complete  and  effect  restoration  of  the  parts :  without 
attention  to  them  it  is,  as  a  rule,  too  feeble  to  accomplish,  unaided,  the 
desired  result. 

Let  us  suppose  that  we  are  dealing  with  a  case  of  prolapse  in  the  first 
or  second  degree,  what  pessary  should  we  choose  ?  This  will  depend  upon 
the  amount  of  weight  to  be  sustained.  If  this  be  great,  subinvolution  of 
the  uterus  existing,  and  depressing  the  organ,  very  possibly  no  internal 
pessary  will  succeed  ;  if  it  be  moderate,  almost  any  one  of  this  list  will  do 
so — Meigs's  elastic  ring,  Hodge's,  Smith's,  Hewitt's,  or  Thomas's  pessa- 
ries, all  of  which  are  shown  by  diagrams  in  connection  with  retroversion. 


PESSARIES. 


403 


Fig.  145. 


None  should  be  used  which  distends  the  vagina,  and  that  employed  should 
be  worn  without  any  sense  of  discomfort ;  should  be  kept  (lean  by  irriga- 
tion with  astringent  fluid  every  night,  or  night  and  morning  ;  and  should 
be  examined,  at  intervals,  by  the  physician,  to  make  sure  that  it  is  not 
injuring  the  tissues. 

If  the  great  weight  of  the  uterus  render  these  pessaries,  which  pass  en- 
tirely into  the  vagina,  ineffectual,  or  should  the  case  be  one  of  prolapse  in 
the  third  degree,  others,  which  are  in  part  external  and  in  part  internal, 
should  be  employed.  I  very  rarely  attempt  to  sustain  a  completely  prolapsed 
uterus  by  an  internal  pessary,  because  I  usually  despair  of  success,  and 
because  I  have  known  such  evil  consequences  result  from  them  in  such 
cases,  that  I  am  unwilling  to  let  the  patient  pass  out  of  my  sight  with  one 
in  place.  It  is  safer,  more  effectual,  and  more  comfortable  for  both  phy- 
sician and  patient  that  she  should  wear  an  instrument  which  she  can 
remove  at  will,  allow  the  parts  to 
rest  during  the  hours  of  recumbency, 
and  replace  upon  rising. 

There  are  three  methods  by  which 
such  support  may  be  furnished,  by  a 
stem  curling  over  the  perineum,  by 
one  passing  out  of  the  vagina  over 
the  symphysis  pubis,  and  by  one  end- 
ing at  the  middle  of  the  vulvar  open- 
ing, and  resting  upon  a  bandage 
passing  beneath  it.  Of  these  plans, 
the  best  is  the  first,  and  the  next,  in 
merit,  the  second.  The  third  is  ob- 
jectionable on  account  of  the  want 
of  some  point  of  support  against 
which  to  fix  the  distal  extremity  of 
the  stem,  and  to  prevent  motion  in 
it. 


Fig.  146. 


Cutter's  prolapsus  pessary  in  position. 
Fig.  147. 


Cutter's  prolapsus  pessary. 


Thomas's  modification. 


404  ASCENT    AND    DESCENT    OF    THE    UTERUS. 

No  pessary  with  which  I  am  acquainted,  so  universally  answers  the 
indications  of  supplementing  the  action  of  the  utero-sacral  ligaments  and 
sustaining  the  prolapsed  vagina,  rectum,  and  bladder  as  Cutter's  admirable 
pessary,  shown  in  Figs.  145  and  146.  The  cup  at  its  upper  extremity 
receives  the  cervix  uteri,  and  the  simplicity  of  the  instrument  enables  the 
patient  to  remove  and  replace  it  with  perfect  facility.  This  should  be 
done  in  the  recumbent  posture  upon  retiring  at  night  and  rising  in  the 
morning. 

Means  for  preventing  traction  by  the  vagina  : — 
Perineal  support ; 
Perineorrhaphy  ; 
Colporrhaphy. 

Perineal  Support. — I  have  already  pointed  out  the  important  function 
of  the  perineal  body  in  closing  the  mouth  of  the  vagina  and  offering  a  but- 
tress for  the  support  of  its  walls.  "When  rupture  of  the  perineum  occurs, 
its  sphincteric  powers  are  destroyed,  and  the  result  is  sagging  of  one  or 
both  columns  of  the  vagina  and  coincident  descent  of  the  uterus.  By  firm 
pressure  at  the  weak  spot,  by  means  of  a  pad  or  cushion  filled  with  hair, 
cotton,  or  air,  and  combined  with  an  abdominal  supporter,  to  which  it 
may  be  attached,  partial  relief  is  sometimes  obtained. 

Perineorrhaphy. — Much  more  complete  and  permanent  support  may  be 
given  to  the  vagina,  and  prolapse  of  its  walls  be  much  more  certainly  ob- 
viated, by  restoration  of  the  perineal  body  by  the  operation  of  perineor- 
rhaphy. If  the  uterus  be  not  very  heavy,  this  operation  often  proves  a 
very  excellent  means  of  relief,  for  it  removes  the  tractile  power,  which 
pulls  down  this  organ,  and  thus  the  cause  of  the  accident  is  taken  away. 
But  this  operation,  although  efficient  in  these  cases,  is  not  likely  to  prove 
so  where  so  heavy  a  weight,  as  a  much  enlarged  uterus,  requires  support. 

It  must  not  be  supposed  that,  in  cases  of  prolapsed  vagina,  perineor- 
rhaphy is  limited  to  instances  in  which  the  perineal  body  is  ruptured.  It 
is  equally  applicable  to  those  in  which  it  has  lost  its  power  from  any  of 
those  influences  which  are  mentioned  in  the  chapter  upon  the  perineum  ; 
such  as  subinvolution,  etc.  etc. 

In  all  cases,  to  be  effectual,  perineorrhaphy  must  restore  the  lost  organ, 
the  perineal  body,  and  not  simply  shut  the  evil  from  sight  by  drawing  be- 
fore it  a  thin  and  useless  curtain,  which  extends  from  the  fourchette  to 
the  anus. 

Should  this  operation  not  be  sufficient  to  remove  traction,  colpo-perine- 
orrhaphy,  or  anterior  or  posterior  colporrhaphy,  or  a  combination  of  these 
may  be  practised. 

For  these  procedures  the  reader  is  referred  to  chapters  which  have  gone 
before. 

By  there  means  traction  is  taken  away  from  the  uterus,  and  if  this  was 


ANTEVERSION  OF  THE  UTERUS.  405 

the  cause  of  its  prolapse  relief  will  probably  follow,  but  it  is  never  safe  to 
promise  a  good  and  permanent  result  from  any  of  the  operations  of  colpor- 
rhaphy.  If  in  a  case  of  laceration  of  the  cervix,  relaxation  of  the  vagina, 
and  complete  distention  or  rupture  of  the  perineum,  the  patient  is  willing 
to  submit  to  three  operations — operation  upon  the  cervix,  colporrhaphy 
upon  anterior  wall,  and  closure  of  the  perineum — cure  will  often  be  com- 
plete and  permanent.  This  is  a  trying  ordeal,  both  mentally  and  physi- 
cally ;  nevertheless,  most  women  affected  by  prolapsus  in  the  third  degree 
would  unhesitatingly  accept  one  of  even  greater  severity  with  the  prospect 
of  cure. 

Besides  the  operations  here  mentioned  as  practised  upon  the  vaginal 
walls,  Episiorrhaphy,  which  has  been  already  described,  has  at  various 
times  been  resorted  to  as  a  curative  or  palliative  process  for  the  affection 
of  which  we  are  treating.  This,  too,  has  been  variously  combined  and 
modiiied,  as,  for  example,  under  the  names  of  Inferior  Elytrorrhaphy, 
Elytro-episiorrhaphy,  Episio-perineorrhaphy,  etc.  For  fear  of  confusing 
the  subject  by  the  introduction  of  details  which,  although  highly  interest- 
ing, are  of  no  great  practical  value,  I  shall  not  describe  these  modified 
procedures,  but  pass  them  by  with  this  mention. 

Not  only  have  efforts  of  this  kind  been  made  for  narrowing  the  vagina 
and  creating  an  artificial  cicatricial  anterior  or  posterior  column  for  the 
support  of  the  uterus  ;  the  actual  cautery,  mineral  acids,  escharotics,  ulce- 
ration created  by  galvanic  pessaries,  and  sloughing  produced  by  pressure 
by  forceps,  have  all  been  tried  for  the  accomplishment  of  the  much-desired 
end.  I  shall  not  go  into  the  detail  of  describing  these  procedures,  but 
refer  the  reader,  who  desires  further  information  upon  them,  to  Scanzoni's 
work  upon  the  Diseases  of  Females.  All  these  methods  have  the  disad- 
vantages of  proving  excessively  painful,  after  anaesthetic  influence  has 
passed  off,  and  of  being  more  unmanageable  and  less  certain  in  their  results 
than  those  here  described. 


CHAPTER   XXVII. 

ANTERIOR  DISPLACEMENTS  OF  THE  UTERUS. 

Anteversion. 

Definition  and  Frequency This  disorder  of   position  consists  in  an 

anterior  inclination  of  the  uterus,  so  that  the  fundus  approximates  the 
symphysis  pubis  and  the  cervix  retreats  into  the  hollow  of  the  sacrum. 
Although  not  so  frequent  as  its  kindred  condition,  anteflexion,  it  is  by  no 
means  of  rare  occurrence.     At   times  it  presents  itself  as  an  annoying 


406  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

complication  of  areolar  hyperplasia  or  fibroid  growths,  while  at  others  it 
is  produced  without  any  alteration  existing  in  the  uterine  parenchyma. 

Dr.  Churchill1  opens  his  chapter  upon  this  subject  with  these  words : 
"  It  may  be  thought  somewhat  out  of  place  to  treat  of  some  of  these  dis- 
placements here,  as  they  are  so  intimately  connected  with  pregnancy  and 
parturition  ;  but  as  they  do  occur  independently,  it  appears  to  me  prefera- 
ble to  travel  so  far  out  of  the  way  in  order  to  complete  the  subject,  rather 
than  give  a  partial  view,  or  omit  it  altogether."  My  own  experience  leads 
me  to  an  entirely  different  conclusion  from  that  here  recorded  by  the  emi- 
nent Irish  obstetrician.  1  meet  with  versions  very  commonly  in  the  non- 
puerperal state,  although  it  must  at  the  same  time  be  admitted  that  anterior 
displacements  generally  assume  the  character  of  flexions.  To  give  some 
idea  of  the  relative  frequency  of  the  various  anterior  and  posterior  dis- 
placements, I  present  the  following  tables.  The  first  table  is  one  con- 
structed from  a  valuable  statistical  report  by  Dr.  Meadows: — 

Number  of  cases  of  displacement  examined 

"  "  posterior  displacement         52 


anterior  displacement  32  -J 


Retroflexion 

.     34 

Retroversion 

.     18 

Anteflexion 

.     20 

Anteversion 

.     12 

It  is  impossible  to  reconcile  the  discrepancy  of  the  results  obtained  by 
statistical  evidence  accumulated  by  different  observers.  Thus,  for  example, 
out  of  339  cases  of  displacement  recorded  by  M.  Nonat,2  the  following 
were  the  number  of  anterior  and  posterior  inclinations : — 

Anteversion  .......  135 

Anteflexion  .......  33 

Retroversion  .......  07 

Retroflexion 14 

"  Anteversion,"  says  Klob?s  "  in  general  is  a  rare  form  of  displacement, 
and  occurs  much  less  frequently  than  retroversion." 

Emmet,  out  of  555  cases  of  version,  found  236  to  be  anteversion  and 
295  retroversion. 

Subjects  of  this  character  belong  to  that  class  upon  which  reasoning 
and  theorizing  accomplish  no  good,  but  rather  the  contrary.  The  only 
way  in  which  they  can  be  settled  is  by  carefully  collected  statistics,  and 
one  would  suppose  that  this  method  would  be  conclusive.  Yet  we  see  in 
the  present  case  how  far  this  is  from  being  the  fact.  Dr.  Meadows's  most 
frequent  displacement  is  M.  Nonat's  and  Scanzoni's  least  frequent! 
Nothing  but  discrepancy  and  doubt  result  from  the  comparison  of  the 
figures  of  these  three  conscientious  observers.     "There  is  nothing,"  said 

'  Diseases  of  Women,  Am.  ed.  *  Mai.  de  l'Ute>us,  p.  416. 

3  Klob,  Patholog.  Anat.,  p.  68. 


ANTEVERSION  OF  THE  UTERUS.  407 

Sydney  Smith,  "  so   unreliable  as  figures,  except   facts."     After  such   a 
comparison  of  statistical  evidence  one  feels  inclined  to  agree  with  him. 

The  normal  position  of  the  uterus  is  one  of  slight  anteversion,  the  axis 
of  the  body  corresponding  with  that  of  the  superior  strait,  which  is  a  line 
running  from  the  umbilicus,  or  a  little  above  it,  to  the  coccyx. 

The  degree  of  this  forward  inclination  may  be  so  increased  by  slight 
causes  as  to  constitute  a  morbid  state.  As  to  the  line  which  separates 
what  is  normal  from  what  is  abnormal,  it  is  impossible  to  lay  down  any 
exact  rule  ;  experience  must  be  our  guide.  In  general  terms  we  may  say, 
that  when  the  long  axis  of  the  uterus  is  found  lying  across  the  pelvis,  the 
fundus  near  the  symphysis  pubis,  and  the  neck  in  the  hollow  of  the  sacrum, 
anteversion  exists. 

Predisposing   Causes The   predisposing   causes  of  this  affection  are 

parturition,  enfeebled  muscular  condition,  habits  of  indolence  and  inac- 
tivity, and  loss  of  tone  in  the  abdominal  walls. 
The  exciting  causes  may  thus  be  presented. 
Influences  increasing  the  weight  of  the  uterus. 
Congestion  ; 

'Hypertrophy  or  hyperplasia  ; 
Subinvolution  ; 
Fibroids ; 
Pregnancy  ; 

Laceration  of  the  cervix. 
Influences  forcing  the  fundus  directly  forwards. 
Violent  efforts ; 
Abdominal  effusions ; 
Abdominal  tumors  ; 
Tight  clothing. 
Influences  enfeebling  uterine  supports. 
Ruptured  perineum  ; 
Relaxation  of  ligaments  ; 

Destruction  of  the  retentive  power  of  the  abdomen.     Cysto- 
cele. 
Influences  dragging  the  fundus  directly  forwards. 
False  membranes  ; 
Prolapsus  vagina*  ; 
Cystocele ; 

Shortness  of  the  round  ligament;  (?) 
Anteflexion. 
A  large  number  of  cases  will  be  found  due  to  areolar  hyperplasia,  a 
number  by  no  means  inconsiderable  to  fibrous  tumors,  some  of  the  most 
irremediable  cases  to  false  membranes,  many  to  cystocele  which  takes 
away  support  at  the  same  time  that  it  produces  traction,  while  a  few  will 
exist  without  other  apparent  cause  than  direct  pressure  from  some  power 


408  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

which  forces  down  the  abdominal  viscera  upon  the  fundus.  The  last 
cause  is  much  aided  by  laxity  of  the  abdominal  walls,  which  robs  the 
viscera  of  support. 

One  fruitful  source  of  the  condition  is  unquestionably  the  gradual  de- 
struction of  the  retentive  power  of  the  abdomen  by  habits  which  engender 
atony  of  the  thoracic  and  abdominal  respiratoiy  muscles  and  enfeeblement 
of  the  action  of  the  diaphragm. 

Symptoms In  a  certain  number  of  cases  anteversion  will  be  found 

to  exist  without  creating  any  disturbance  either  constitutional  or  local. 
This,  however,  is  a  rare  exception  to  a  general  rule.  By  pressure  of 
the  os  against  the  posterior  vaginal  wall,  anteversion  commonly  induces 
dysmenorrhcea  and  sterility,  and  by  pressure  of  the  fundus  against  the 
bladder,  and  the  cervix  against  the  rectum,  these  viscera  are  irritated  and 
interfered  with  in  their  functions.  The  bladder  more  especially  suffers, 
sometimes  a  state  bordering  upon  cystitis  being  engendered.  Pressure 
upon  the  rectum  more  rarely  produces  tenesmus  and  a  painful,  irritable 
state. 

In  exceptional  cases  it  is  surprising  to  see  to  how  great  an  extent  loco- 
motion is  affected  by  this  condition.  My  experience  furnishes  me  with 
four  cases  in  which  patients  were  for  long  periods  confined  to  bed  or  the 
lounge  on  this  account.  In  one  of  these  the  patient  had  not  left  the  house 
for  four  years  ;  in  another  she  had  scarcely  assumed  the  upright  posture 
for  eight  months  ;  the  third  was  the  counterpart  of  the  second  ;  while  in  the 
fourth  the  patient  for  twelve  years  had  never  walked  over  a  quarter  of  a 
mile  without  serious  inconvenience.  In  each  of  these  cases  positive  proof 
was  afforded  me  of  the  agency  of  anteversion  in  producing  the  disability 
which  existed,  by  its  removal  when  the  uterus  was  properly  sustained  by 
an  anteversion  pessary,  and  by  relapse  at  once  recurring  when  without 
her  knowledge  she  was  left  without  it.  Not  one  of  these  women  was  suffer- 
ing from  that  hysterical  condition  which  so  often  misleads  the  physician 
as  to  the  results  of  remedies. 

Course,  Duration,  and  Termination. — Even  if  the  exciting  cause  of  the 
condition  be  removed,  it  will  usually  continue,  for  the  broad  and  utero- 
vesical  ligaments  have  by  long  distention  become  stretched  and  enfeebled, 
while  there  has  been  simultaneous  contraction  in  the  utero-sacral  liga- 
ments from  long  disuse.  The  first  fail  to  aid  the  fallen  organ ;  the  last 
help  to  keep  it  out  of  position  by  lifting  the  cervix  up  against  the  rectum. 
Sometimes  cure  is  affected  by  pregnancy,  the  displacement  disappearing 
as  involution  is  accomplished.  Usually,  however,  unless  the  exciting  cause 
of  the  condition  be  removed,  and  the  organ  be  kept  in  proper  position  for 
a  year  or  more,  the  displacement  will  continue  unabated. 

Varieties. — Anteversion  may  be  complete  or  partial.  While  there  are 
three  degrees  of  retroversion  and  of  prolapse,  there  are  but  two  of  this 
displacement,  for  the  axis  of  the  uterine  body  is  naturally  inclined  so  much 


ANTEVERSION    OF    THE    UTERUS. 


■109 


forwards  as  to  prevent   us  from  including  slight   increase  of  inclination 
under  the  head  of  disease. 

Fig.  148  will  show  the  varieties  referred  to;  an  inclination  of  45°  re- 
presenting the  first  degree,  or  partial  anteversion,  and  that  of  90°  the 
second  degree,  or  complete  anteversion. 

Fio.  148. 


The  degrees  of  anteversion. 

Diagnosis — When  in  a  case  of  this  displacement  vaginal  touch  is  prac- 
tised, the  patient  lying  on  the  back,  the  index  finger  passed  into  the  fornix 
vagina?  discovers  that  the  cervix  is  absent.  A  rapid  investigation  will 
prove  that  it  is  not  to  be  found  in  the  pubic  or  lateral  regions  of  the  pelvis, 
and  deep  exploration  with  two  fingers  will  discover  it  high  up  in  the  hol- 
low of  the  sacrum.  The  finger  being  then  passed  towards  the  pubes  will 
come  in  contact  with  a  hard  ridge,  which  will  run  towards  the  symphysis. 
Conjoined  manipulation  will  prove  this  to  be  the  body  of  the  uterus,  and 
complete  the  diagnosis.  Should  further  evidence  be  required,  the  uterine 
probe,  very  much  curved,  may  be  passed  into  the  cavity,  though  this  is 
rarely  necessary  and  always  difficult. 

Differentiation. — Capuron  tells  us  that  Levret  mistook  the  first  case 
he  saw  for  stone  in  the  bladder,  operated  for  this,  and  sacrificed  the  life 
of  the  patient.  In  spite  of  such  a  grave  mistake  at  the  hands  of  so  great 
an  authority,  it  may  be  stated  that  there  is  no  diseased  condition  with 
which  this  should  be  confounded.  The  disease  inducing  the  displacement 
may  not  be  recognized,  or  some  serious  error  may  be  made  as  to  its  nature, 


410  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

but  that  does  not  concern  the  present  subject.  The  recognition  of  the 
mere  fact  of  the  anteversion  is  never  difficult,  if  proper  diagnostic  means 
are  brought  to  its  elucidation. 

Prognosis The  prognosis  as  to  any  serious   injury  which  will   arise 

from  the  displacement  is  decidedly  good,  although  there  are  many  incon- 
veniences and  discomforts  connected  with  it,  such,  for  example,  as  vesical 
and  rectal  irritation,  neuralgia  in  consequence  of  compression  of  the  nerves, 
and  difficulty  in  locomotion  ;  none  of  these,  however,  go  on  to  a  dangerous 
degree  of  development.  If  the  condition  be  not  treated  by  mechanical 
means,  it  will  prove  entirely  incurable  ;  but  by  these  the  prospect  of  great 
improvement  and  even  of  complete  cure  is  very  good.  Important  and 
early  evidences  of  improvement  resulting  from  mechanical  treatment  are 
frequently  obtained  in  disappearance  of  dysmenorrhoea  and  sterility.  It 
is  often  difficult  to  remove  the  exciting  cause  of  anteversion,  and  even 
should  this  be  accomplished,  the  uterus  is  so  prone  to  retain  the  abnormal 
position  in  which  it  has  long  been  kept,  that  great  difficulty  attends  its 
retention  in  normal  position.  One  of  the  reasons  for  this  is  the  fact, 
already  stated,  that  the  uterine  ligaments  readily  alter  their  proportions 
under  certain  influences.  Thus  during  pregnancy  they  are  all  elongated  ; 
in  posterior  displacements  the  utero-sacral  ligaments  are  stretched,?  and 
in  anterior  inclination  the  utero-vesical  ligaments  are  similarly  affected. 
As  the  antithesis  of  this  fact,  prolonged  absence  of  function  causes  con- 
traction in  these  structures ;  thus  in  anteversion  the  utero-sacral  ligaments 
are  generally  shortened,  and  there  is  no  doubt  that  the  round  ligaments 
are  similarly  altered. 

Anteflexion. 

Definition This,  which  is  one  of  the  most  frequent  of  all  uterine  dis- 
placements, consists  in  a  bending  of  the  organ  so  that  the  fundus,  the 
cervix,  or  both,  are  bent  more  or  less  sharply  forwards. 

Varieties There  are  three  forms  of  anteflexion  :  first,  corporeal  flexion  ; 

second,  cervical  flexion;  third,  cervi co-corporeal  flexion. 

1st.  The  cervix  being  normal  in  position  the  body  is  flexed  ; 
2d.  The  body  being  normal  in  position  the  cervix  is  flexed  ; 
3d.   Both  are  flexed  forwards. 
The   lines  represented  in  Fig.  150  will  serve  to  show  the   deviations 
which  may  affect  the  axes  of  both  body  and  cervix. 

These  varieties  are  neither  arbitrary  nor  unnecessary.  The  existence 
of  each  may  readily  be  verified  at  the  bedside,  and  treatment  should 
always  be  materially  modified  by  the  peculiarity  of  the  deviation.  It 
appears  to  me  that  a  neglect  of  them  and  (lie  fixation  of  attention  upon 
flexure  of  the  body  alone  has  seriously  retarded  progress  in  treatment. 
No  one  can  intelligently  treat  anteflexion  without   regard   being  had  to 


ANTEFLEXION    OF    THE    UTERUS, 


411 


the   variety  of   the   disorder   to   which    he    is   culled   upon    to   adapt    his 
mechanical  appliances. 

Fig.  149. 


Anteflexion. 


In  addition  to  these  there  is  a  rare  form  in  which  the  cei'vix  is  flexed 
forwards  and  the  body  backwards,  but  it  is  difficult  to  represent  the  axes 
of  this  variety  in  a  diagram. 


(   r 


Fig.  150. 


Normal  axes. 


First  variety  of 
flexion. 


Second  variety  of 
flexion. 


Third  variety  of 

flexion. 


Symptoms A  certain  degree  of  this  displacement  may  exist  for  years 

without  the  development  of  symptoms.  Very  generally,  however,  obstruc- 
tion to  venous  return  at  the  point  of  flexure  produces  congestion  which 
increases  the  displacement,  disturbs  the  nervous  system,  and  disorders 
uterine  functions.     Then  the  following  symptoms  develop  themselves  : — 

Pain  over  hypogastrium  and  in  groins  and  back; 

Irritable  bladder; 

Leucorrhoea ; 


412  ANTERIOR    DISPLACEMENTS    OP    THE    UTERUS. 

Dysmenorrhea ; 

Sterility ; 

Nervous  disturbance  and  despondency ; 

Pain  on  locomotion ; 

Menorrhagia ; 

Tendency  to  abortion ; 

Pain  on  sexual  intercourse ; 

Pelvic  neuralgia; 

Sense  of  depression  at  the  epigastrium. 
In  some  cases  there  is  a  morbid  and  invincible  aversion  to  walking, 
partly  arising  from  physical  and  partly  from  mental  causes.  I  have,  in 
several  cases,  seen  women  who  had  been  bedridden  for  three  and  four 
years  rapidly  restored  to  their  powers  of  locomotion  by  restoration  of  the 
uterus  to  position,  and  its  retention  by  an  efficient  pessary. 

Dr.  Hewitt  mentions  the  retention  of  secundines  after  abortion  in  cases 
of  anteflexion,  and  their  putrefaction  in  utero,  and  advises  as  treatment 
restoring  the  organ  to  place,  when  expulsion  at  once  occurs. 

Physical  Signs — As  the  finger  passes  into  the  vagina  and  touches  the 
cervix,  nothing  abnormal  will  usually  be  discovered.  But  as  it  sweeps 
along  the  anterior  wall  of  the  uterus,  about  the  os  internum  a  protuberance 
will  be  met  with  which  presses  upon  the  bladder.  The  finger  which  has 
thus  far  explored  being  kept  in  contact  with  this  mass,  the  disengaged 
hand  should  then  be  laid  upon  the  abdomen  and  made  to  depress  the 
anterior  abdominal  wall  so  as  to  approximate  the  finger  in  the  vagina. 
By  this  means  the  shape,  size,  and  sensitiveness  of  the  body  may  be  ascer- 
tained. The  diagnostician  is,  however,  still  in  doubt  whether  the  enlarge- 
ment may  not  be  one  due  to  fibrous  tumor  or  cellulitis.  This  point  he 
settles  by  placing  the  patient  on  the  side,  introducing  Sims's  speculum, 
and  gently  probing  the  uterus  to  the  fundus.  Giving  to  the  probe  the  curve 
which  by  vaginal  touch  he  has  been  informed  is  that  of  the  uterus,  he 
carefully  passes  it  in.  Should  it  not  proceed  without  obstruction,  he  with- 
draws it,  alters  the  curve,  and  tries  again.  Having  succeeded  in  intro- 
ducing it,  he  learns  the  course  of  the  uterine  canal,  its  length,  and  the 
sensitiveness  of  its  walls.  Should  the  probe  have  entered  the  mass  felt 
through  the  vagina,  that  mass  is  the  uterine  body.  Should  it  go  in  the 
normal  axis  or  backwards,  it  is  not  the  uterine  body,  but  some  growth  in 
contact  with  it.  In  pure  cervical  flexion  the  neck  will  be  felt  sharply 
bent  forwards  and  in  the  double  form  both  neck  and  body  will  be  found 
flexed. 

Prognosis The  prognosis  as  to  cure  will  depend  upon  certain  circum- 
stances which  I  will  proceed  to  enumerate. 

(a)  It  is  better  in  multiparous  than  in  nulliparous  women,  because  the 
vagina  in  the  former  more  readily  admits  of  the  use  of  mechanical  supports, 
and  because  it  is  acquired  and  not  congenital. 


TREATMENT    OF    ANTERIOR    DISPLACEMENTS.  41.J 

(b)  It  is  better  in  pure  corporeal  anteflexion  than  in  those;  varieties  in 
which  the  cervix  is  affected. 

(c)  Where  the  cervix  is  thrown  far  back  and  lifted  high  in  the  pelvis, 
the  prognosis  is  decidedly  unfavorable,  and  more  especially  if  there  exist 
only  a  scanty  vaginal  pouch  anterior  to  the  neck. 

(d)  If  the  flexion  be  of  reducible  kind,  prognosis  is  favorable;  if  the 
contrary,  it  is  by  no  means  so. 

(e)  The  prognosis  of  congenital  flexion  is  almost  a  hopeless  one,  unless 
the  knife  be  resorted  to. 

(/')  Of  all  the  cases  except  the  last  the  prognosis  is  most  unfavorable  in 
those  in  which  the  vagina  joins  the  cervix  very  low  down,  near  the  os 
externum,  and  where  the  uterus  is  held  high  in  the  pelvis. 

The  shibboleth  of  the  subject  of  prognosis  as  to  cure  is,  however,  this : 
if  the  flexion  be  entirely  reducible,  the  case  may  be  cured ;  if  it  be  not  so, 
it  will  in  all  probability  prove  incurable. 

As  regards  the  general  health  of  the  patient,  the  prognosis  is  not  usually 
bad,  but  enlargement  of  the  uterine  body  may  result  from  anteflexion,  and 
its  consequences  are  commonly  sterility,  vesical  irritability,  dysmenorrhea, 
and  leucorrhcea. 

Treatment  of  Anterior  Displacements The  first  point  which  the  prac- 
titioner should  settle  before  commencing  treatment,  is  whether  the  dis- 
placement is  the  main  source  of  existing  morbid  phenomena,  or  whether 
these  are  due  to  some  disease  which  underlies  that  condition.  If  he  be 
led  to  regard  it  as  merely  a  coincident  or  resulting  condition  which  is 
producing  no  annoyance,  of  course  the  primary  disorder  must  take  pre- 
cedence of  it  in  treatment.  It  is,  however,  futile  to  assume  the  position 
that  not  the  displacement,  but  its  cause,  must  be  the  main  object  of  atten- 
tion ;  that,  if  endometritis,  subinvolution,  or  a  fibroid  be  its  cause,  they, 
and  not  it,  must  be  treated.  Kothing  so  surely  prevents  success  in  the 
management  of  such  cases  as  the  carrying  into  practice  of  the  theoretical 
view  that  support  must  be  confined  to  cases  of  pure,  uncomplicated  dis- 
placement. It  is  very  often  required  where  this  is  a  result  or  complication 
of  other  disease.  We  are  called  upon  to  alleviate  one  of  the  most  annoy- 
ing symptoms  of  disease  here,  as  we  are  in  so  many  other  instances.  Pes- 
saries are  frequently  required  by  the  uterus  as  splints  are  by  a  fractured 
bone,  not  absolutely  as  a  means  of  cure,  but  as  adjuvants  in  treatment,  by 
which  rest  and  freedom  from  pain  can  be  procured  while  the  healing  pro- 
cess advances. 

Means  for  Reduction In  the   restoration  of  an  anteverted   uterus  to 

its  place,  difficulty  will  rarely  be  experienced,  for,  unlike  retroversion, 
the  displacement  does  not  often  become  complete.  Even  when  it  does  so, 
reduction  may  be  easily  accomplished.  When  it  proves  difficult,  the 
bladder  having  been  emptied  by  the  catheter,  the  patient  should  be  placed 
upon  her  back  on  a  hard  bed  or  table,  and  all  tight  clothing  removed 


414  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

from  the  abdomen.  The  operator  having  oiled  two  fingers  should  then 
pass  them  into  the  vagina,  and  press  their  tips  against  the  body  of  the 
uterus,  which  will  have  forced  the  walls  of  the  bladder  down  before  it. 
The  fingers  of  the  left  hand  being  thus  employed,  the  right  should  be  laid 
upon  the  abdomen,  so  as  to  push  up  the  abdominal  viscera  and  uterus 
when  reduction  is  attempted.  The  patient  is  now  directed  to  fill  the 
lungs  with  air,  and  then  to  expel  it  gently  by  a  prolonged  expiratory  act. 
As  this  expiration  is  being  finished,  the  operator  presses  up  the  body  of 
the  uterus  by  the  fingers  in  the  vagina,  and  the  abdominal  viscera  and 
fundus  by  the  hand  on  the  abdomen.1  He  will  generally  succeed  at  once 
in  replacing  the  organ.  Should  he  not  do  so,  he  should  repeat  the  process 
as  above  described,  until  the  end  is  attained.  Of  course  where  the  dislo- 
cation is  partial,  restoration  may  be  much  more  easily  effected ;  but  in 
this  case  it  accomplishes  nothing,  for  no  sooner  does  the  force  applied 
cease,  than  the  organ  again  falls  out  of  place.  As  the  fundus  is  lifted  by 
bimanual  manipulation,  the  hand  on  the  abdomen  keeping  it  up,  the  finger 
in  the  vagina  should  be  placed  behind  the  cervix,  and  this  part  be  pulled 
forwards  towards  the  symphysis. 

Some  practitioners  rely  lor  cure  upon  the  daily  restoration  of  an  ante- 
verted  or  retroverted  uterus,  but  hopes  thus  based  will  usually  prove 
delusive.  "Where  the  version  is  complete  and  sudden,  a  return  to  the 
normal  position  may  be  final ;  but  rarely  have  I  seen  it  so  result  where 
the.  displacement  was  incomplete  and  chronic. 

The  method  just  described  is,  unless  the  uterus  be  bound  down  by  false 
membranes,  very  generally  successful  in  anteversion.  In  anteflexion 
also,  where  the  displacement  is  one  of  reducible  character,  it  is  often  all 
that  is  required.  But  in  cases  of  anteflexion  irreducible  in  character  or 
difficult  of  reduction,  more  efficient  means  must  be  resorted  ,to.  These 
may  be  enumerated  as  the  uterine  sound,  Elliott's  repositor,  Jennison's 
sound,  and  "Wallace's   spring  tent,  or  laminaria  tents. 

Of  course  such  restoration  is  only  temporary,  but  even  that  benefits 
uterine  circulation  and  improves  the  nutrition  of  the  enfeebled  concave 
wall.  I  have  elsewhere  likened  the  flexed  uterus  to  a  bent  twig.  The 
replacement  of  the  former  may  be  compared  with  the  straightening  of 
such  a  twig  by  the  forester,  and  the  use  of  a  pessary  to  the  employment 
of  the  supporting  splint  which  he  binds  to  the  growing  tree  and  by  which 
he  strengthens  its  weak  side. 

The  uterine  sound  being  introduced  to  the  fundus,  not  much  curved,  but 
as  straight  as  it  can  be  made  to  pass,  the  handle  being  held  in  one  hand, 
the  tips  of  the  fingers  of  the  other  should  be  pressed  against  the  shaft  of 
the  sound  near  the  middle,  and   they  being  made  a  fulcrum,  the   handle 

1  The  operator  should  be  very  sure  that  the  anteverted  uterus  is  not  bound 
down  by  false  membranes  before  applying  force  for  its  replacement. 


MEANS    FOR    REDUCTION. 


415 


should  be  carried  to  the  symphysis.  By  this  manoeuvre  the  flexed  fundus 
is  elevated,  and  at  the  same  time  carried  towards  the  hollow  of  the  sacrum. 
This  point  being  reached,  the  sound  should  be  very  gently  rotated,  and 
complete  retroversion  with  partial  retroflexion  of  the  uterus  accomplished. 
This  should  be  done  with  the  utmost  gentleness,  and  as  I  have  described, 
not  by  a  sudden  rotation  of  the  flexed  organ,  which  forcibly  sweeps  the 
fundus  around  the  superior  strait  of  the  pelvis. 

Sims's  speculum  being  introduced  and  the  cervix  caught  by  a  tenacu- 
lum,  Elliott's  sound,  shown  in  Fig.   151,  may  be  carried   quite  curved 

Fig.  151. 


Elliott's  uterine  repositor. 

into  the  flexed  uterus  and  straightened  by  the  action  of  the  screw  at  its 
lower  end. 

A  method  of  reposition  which  I  prefer  to  these  in  anteflexion  is  that  hy 
the  use  of  Jennison's  sound,  Fig.  152. 

Fig.  152. 


Jeuuisoa's  sound. 


Pressure  upon  the  lower  extremity  of  this  causes  the  upper  to  bend 
sharply  so  that  it  readily  enters  a  flexed  uterus.  Then  reversal  of  this 
pressure  lifts  the  flexed  body,  and  not  only  straightens  the  uterine  axis 
but  creates  retroflexion. 

Every  succeeding  exercise  of  the  uterus  in  this  straightening  process 
renders  reposition  easier,  improves  the  nutrition  of  the  flexed  wall,  and 
benefits  the  circulation  in  the  organ.      After   this   has  been  done  four  or 


416  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

five  times  the  second  indication  should  be  attempted,  keeping  the  uterine 
body  in  position. 

In  a  large  number  of  cases  of  anteflexion,  however,  even  these  means 
of  replacement  prove  unavailing,  and  the  deformity  of  the  uterus  is  sus- 
ceptible of  relief  by  two  plans  of  treatment  only  :  that  which,  by  uterine 
tents  and  the  intra-uterine  stem,  forcibly  straightens  the  bent  organ  ;  and 
that  which,  by  the  knife  or  scissors,  renders  the  canal  straight  without 
reference  to  the  relations  of  neck  and  body.  Such  cases  being  commonly 
congenital,  one  wall  is  well  developed  by  excessive  growth,  while  the  other 
is  dense,  rigid,  atrophic,  and  unyielding.  They  may,  however,  result  from 
prolonged  accidental  flexion,  with  development  of  slight  attacks  of  peritoni- 
tis; even  without  the  last,  indeed,  for  cicatricial  retraction  of  the  atrophied 
section  of  connective  tissue  has  been  found  by  Klob  under  these  circum- 
stances. 

One  of  the  most  effectual  means  of  meeting  the  difficulties  of  irreducible 
flexion  is  the  use  of  the  spring  tent  of  Dr.  Ellerslie  Wallace,  of  Philadel- 
phia. He  passes  through  a  canal  made  in  a  piece  of  carbolized  sponge  a 
small  piece  of  watchspring  and  compresses  the  sponge  so  as  to  make  the 
tent  curved  as  represented  in  Fig.  153. 

Fig.  153. 


Ellerslie  Wallace's  spring  tent. 

In  this  condition  it  is  passed  into  the  flexed  uterus,  and  as  the  sponge 
softens,  the  spring  erects  itself  and  straightens  the  uterus.  All  the  dan- 
gers attending  the  use  of  sponge  tents  attend  the  use  of  this,  but  no  more. 
It  may  be  practised  once  a  week  until  three  or  four  tents  are  used,  or  it 
may  be  used  once  and  be  followed  by  the  intra-uterine  stem. 

The  same  end  may  be  obtained  by  moistening  in  hot  water  a  laminaria 
tent  up  to  the  point  of  bending,  and  passing  this  into  the  uterus,  and  keep- 
ing it  there  until  it  fully  expands. 

One  very  important  fact,  however,  which  should  be  constantly  borne  in 
mind  in  connection  with  anteflexion  is,  that  there  is  aclass  of  cases  of  irredu- 


MEANS    OF    RETENTION.  417 

cible  flexions  which  is  incurable.  The  practitioner,  unwilling  to  admit  this 
to  himself,  or  not  appreciating  the  fact,  begins  treatment  from  a  conventional 
idea  that  such  is  his  duty.  But  the  case  proves  far  too  obstinate  for  the 
ordinary  local  treatment;  tents  will  not  cure  it,  and  trachelotomy,  not  fully 
meeting  the  mechanical  indications,  fails  likewise.  If  the  patient  passes 
the  ordeal  without  being  attacked  with  peritonitis  or  cellulitis,  she  in  time 
gives  up  all  efforts  at  cure,  or  seeks  the  advice  of  another  physician. 

Means  of  Retention  in  Position  of  a  Uterus  Anteriorly  Displaced. — 
These  should  be  based,  like  those  adopted  in  all  other  uterine  displacements, 
as  far  as  possible  upon  antagonizing  the  influences  which  produce  and  per- 
petuate the  aberration  from  the  normal  position.  The  repetition  of  this 
fact,  and  of  the  means  for  developing  the  principle  in  connection  with  the 
various  displacements,  may  prove  tedious,  but  1  offer  no  apology  for  this, 
for  the  great  advantage  which  will  result  to  the  student  from  following 
this  course  will  abundantly  justify  me.  It  will  be  said  too,  by  the  many 
who  prefer  empirical  to  scientific  methods,  that  the  plan  pursued  is  based 
upon  theory  which  is  not  applicable  at  the  bedside.  Let  this  question  be 
put  to  the  test  of  experience,  and  the  student  will  find  that  the  mere 
direction  of  the  mind  into  proper  channels  of  thought  and  investigation 
will  give  the  plan  value  and  induce  him  to  adopt  it. 

In  every  case  of  anterior  displacement  let  the  practitioner  endeavor  to 
find  out  which  is  the  main  element  concerned  in  its  production,  but  at  the 
same  time  let  him  remember  that  this  one  has  almost  surely  developed 
others  which  are  scarcely  less  important  as  factors.  In  most  cases,  there- 
fore, he  will  be  called  upon  to  direct  his  attention  to  all  forms  of  the  patho- 
logical influence  about  to  be  mentioned. 

All  increased  weight  of  the  uterus  should  be  treated  by  appropriate 
means  ;  inflammation  and  its  results  by  methods  already  mentioned,  hyper- 
plasia and  hypertrophy  by  means  adapted  to  their  management,  and  lace- 
ration of  the  cervix  by  trachelorrhaphy,  etc.  The  fulfilment  of  this 
indication  alone  will  sometimes  effect  a  complete  cure  of  anteversion. 
Whether  it  does  so  or  not,  the  next  should  always  receive  attention. 

Pressure  from  above  should  be  removed  by  carrying  the  weight  of  the 
clothing  upon  the  shoulders,  by  skirt-supporters;  pressure  of  the  intestines, 
by  prohibition  of  tight  clothing,  the  use  of  an  abdominal  supporter,  and 
the  avoidance  of  injurious  muscular  effort. 

The  dorsal  decubitus  in  cases  occurring  suddenly,  as,  for  example,  during 
pregnancy  or  after  labor,  is  of  great  value,  and  even  in  chronic  cases  is  an 
important  adjuvant  to  treatment  by  pessaries.  In  the  commencement  of 
such  treatment  at  least,  it  should  be  always  adopted,  for  two  or  three 
hours  every  day,  at  mid-day,  for  the  purpose  of  affording  a  temporary 
rest  to  the  parts. 

In  proportion  to  the  disadvantages  resulting  from  corsetting   the  upper 
segment  of  the  trunk,  are   the   advantages  to  be  derived,  in  these  cases, 
27 


418 


ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


from  thus  acting  upon  the  lower.  "When  the  abdominal  walls  are  lax  and 
yielding,  and  do  not  properly  sustain  the  viscera,  they  fall  upon  the  fun- 
dus uteri,  and  tend  to  produce  and  keep  up  anterior  obliquity. 

No  one  can  deny  that  by  a  well-fitting  abdominal  supporter,  tone  is 
given  to  the  lax  walls,  and  that  the  intestines,  not  the  uterus,  are  sus- 
tained. I  have  already  stated  that  many  are  prejudiced  against  this  means 
and  decry  it  as  absolutely  injurious  ;  but  I  see  it  too  plainly  and  certainly 
productive  of  good  results  in  daily  practice  to  admit  of  any  doubt  in  my 
mind  concerning  it.  Dr.  J.  C.  Nott  offered  a  very  plausible  explanation 
of  the  fact  that  in  some  women  benefit  follows  the  use  of  abdominal  sup- 
porters, while  in  others  absolute  injury  results  from  their  employment. 
"  If  the  patient  be  emaciated,"  said  he,  "  and  the  abdominal  walls  retracted 
or  even  flattened,  the  supporter  will  depress  and  not  sustain  the  uterus. 
On  the  other  hand,  if  the  woman  be  corpulent,  the  greatest  support  will 
be  yielded  by  its  application."  I  have  employed  for  this  purpose  with 
very  great  advantage  an  abdominal  pad  or  truss,  which  is  at  the  same 

Fig.  154. 


Abdominal  pad  of  wood  or  cork. 


time  simple,  inexpensive,  and  efficient.  It  consists  of  an  ovoid  block  of 
cedar,  pine,  or  cork,  five  inches  long  by  four  inches  wide.  This  is  con- 
vex upon  the  surface  to  be  placed  next  the  body,  and  flat  on  the  opposite 
side,  and  is  held  in  place  by  an  elastic  band  or  slender  strip  of  steel  covered 


Fig.  155. 


Abdominal  supporter. 

with  leather,  like  an  ordinary  male  truss.  The  pressure  made  resembles 
that  of  the  hand,  and,  as  soon  as  patients  become  accustomed  to  it, 
which  it  should  be  borne  in  mind  may  take  a  little  time,  gives  great  com- 
fort.    Another  very  efficient  one  is  shown  in  Fig.  155. 


MEANS    OF    RETENTION, 


419 


Traction  upon  the  uterus  from  below,  if  found  to  exist,  should  be  re- 
moved by  perineorrhaphy  alone  or  combined  with  colporrhaphy,  or  it  may 
be  obviated  by  the  use  of  a  pessary  which  sustains  vagina,  uterus,  and 
bladder. 

Fig.  156  shows  how  loss  of  power  in  the  perineum  will  result  in  pro- 
lapse of  the  anterior  vaginal  wall,  how  the  bladder  will  in  consequence 
prolapse,  and  how  the  upper  portions  of  the  uterus  will  follow  it,  ante- 
version  resulting,  and  how  perfect  repair  of  the  perineum  will  remove  all 
traction  from  the  uterus,  and  allow  it  to  resume  its  place  in  the  pelvis. 

Fig.  156. 


The  perineal  body  destroyed,  both  rectal  and  vesical  walls  descend. 

Loss  of  the  normal  supports  of  the  uterus  should  be  overcome  by  the 
use  of  general  and  local  tonics,  developing  the  retentive  powers  of  the 
abdomen,  and  by  the  use  of  pessaries.  Astringent  vaginal  injections,  sea- 
bathing, and  the  internal  use  of  vegetable  and  mineral  tonics  are  unques- 
tionably of  value. 

By  the  development  of  the  retentive  power  of  the  abdomen,  a  great 
deal  can  be  done  for  replacement  and  support  of  an  anteverted  uterus. 
Every  morning  and  evening  the  patient  should  place  herself  flat  upon  the 
back  upon  her  bed,  with  the  hands  clasped  over  the  head  and  the  heels 
touching  the  buttocks.  Then  she  should  raise  the  pelvis  as  high  as  possi- 
ble, and  sustain  it  for  a  few  moments,  the  shoulders  and  soles  of  the  feet 
alone  touching  the  bed.  Letting  the  pelvis  slowly  descend,  she  is  to  re- 
peat this  a  half  dozen   times.     The  movement  too  for  strengthening  the 


420  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

abdominal  muscles  mentioned  under  treatment  of  prolapse  should  be  prac- 
tised here,  as  well  as  the  general  exercises  indicated  there  for  the  full 
development  of  the  thoracic  and  dorsal  muscles. 

Pessaries. — "What  is  desired  of  a  pessary  in  sustaining  the  anteflexed 
or  anteverted  uterus  is  this :  to  make  gentle  pressure  on  the  base  of  the 
bladder  above  the  cervico-corporeal  junction,  and  as  near  to  the  fundus  as 
possible,  to  supplement  the  vesico-uterine  ligaments,  and  at  the  same  time 
not  to  injure  the  vagina  by  excessive  pressure  at  this  point.  It  is  by  no 
means  easy  to  make  an  instrument  answer  these  requirements;  it  may 
either  keep  the  uterus  in  place  at  the  expense  of  a  degree  of  force  which 
will  create  a  solution  of  continuity  in  the  vagina,  or  it  may,  when  pos- 
sessed of  too  little  power,  allow  the  fundus  in  spite  of  it  to  fall  forwards. 
The  use  of  pessaries  for  this  displacement  requires  a  vast  deal  more  skill, 
mechanical  ingenuity,  and  patience  than  is  necessary  in  those  of  posterior 
variety.  Even  with  every  precaution,  cases  will  commonly  occur  in  which 
the  parts  will  be  injured  by  pressu  re ;  and  without  precautions  the  means 
is  one  which  is  attended  by  absolute  danger.  In  cases  in  which  pelvic 
peritonitis  has  preceded  the  displacement,  the  danger  is  so  marked  that 
treatment  by  pessaries,  either  should  not  be  adopted  at  all,  or,  if  attempt- 
ed, should  be  limited  to  the  most  cautious  trials. 

The  diagnosis  having  been  made,  and  it  having  been  decided  that 
retention  of  the  uterus  in  position  is  not  attended  by  danger  on  account  of 
former  pelvic  peritonitis,  and  that  the  displacement  results  from  no  condi- 
tion removable  by  operation,  the  treatment  should  be  commenced  in  this 
way.  The  intestines  should  be  evacuated  by  a  cathartic,  all  weight 
removed  from  the  fundus  by  abdominal  and  skirt  supporters,  and  the  pa- 
tient enjoined  to  take  very  moderate  exercise  and  to  avoid  all  violent 
efforts.  Every  night  and  morning  she  should  use  the  warm  vaginal 
douche,  not  only  at  first,  but  throughout  the  duration  of  treatment,  to 
prevent  irritation  from  it.  Before  the  introduction  of  a  pessary,  the 
uterus  should  have  been  several  times  replaced  by  conjoined  manipulation 
and  held  in  position  for  two  or  three  minutes  at  a  time.  At  the  end  of 
this  period,  if  the  displacement  is  readily  reducible,  and  it  requires  no 
great  force  to  sustain  the  uterus,  the  anteversion  pessary  represented  in 
F'ig.  157  may  be  introduced,  and  the  patient  allowed  to  walk  about. 
Should  it  give  no  pain,  she  may  wear  it  home,  even  if  going  to  a  distance 
from  the  practitioner's  residence,  for  she  can  herself  remove  it  on  the  first 
menace  of  injury.  In  three  or  four  days  the  instrument  should  be  ex- 
amined. If  it  have  given  pain  or  have  left  its  mark  upon  the  vaginal 
walls,  it  should  be  changed  at  once ;  if  not,  it  may  be  left  for  a  week ; 
then  for  two  weeks ;  then  for  a  month ;  and  afterwards  for  a  still  longer 
time,  two  months,  for  example,  without  examination.  The  pessary  here 
advised  is  represented  open  for  withdrawal  by  the  dotted  lines,  and  closed 


PESSARIES. 


421 


as  it  should  be  in  the  vagina  in  introduction.  The  piece  which  sustains 
the  fundus  is  large  and  smooth,  so  as  not  to  injure  the  vaginal  wall. 
"When  the  pessary  is  drawn  upon  by  means  of  its  lower  branch,  this  piece 
falls  back  of  itself,  and  thus  the  instrument  is  susceptible  of  removal.     The 


Fio.  157. 


(S, 


\».RlYIIDtRS-Ct>.HE"£--.  .''■'.';. 


Thomas's  anteversion  and  anteflexion  pessary. 


possibility  of  removal  by  the  patient  is  an  important  element  in  an  ante- 
version  pessary,  for  she  may  go  away  after  its  introduction  and  suffer 
agony  in  a  few  hours,  and,  should  she  be  unable  to  remove  it,  inflamma- 
tion might  result.  Even  if  she  obtain  medical  aid,  it  is  often  very  diffi- 
cult for  a  physician  ignorant  of  the  peculiar  construction  of  one  of  these 
instruments  to  remove  it.  I  never  consent  to  a  patient  who  is  wearing 
one  leaving  my  office  to  go  out  of  the  city  without  first  making  myself 
sure  of  her  ability  to  remove  it  herself.  The  pessary  here  represented  is 
introduced  closed  and  carried  to  and  behind  the  cervix  just  as  one  for 
retroversion  is.  As  the  piece  intended  to  support  the  fundus  is  resisted 
by  the  pubes,  the  perineum  is  depressed  and  it  is  carried  under  it.  The 
instrument  is  opened  as  shown  in  the  diagram,  not  for  its  insertion,  but 
for  its  withdrawal.  The  anterior,  projecting  piece  may  be  made  longer 
or  shorter  as  greater  or  less  elevation  of  the 
uterus  becomes  necessary.  Fig.  158  repre- 
sents this  instrument  modified  so  as  to  con- 
sist of  a  permanent  and  immovable  projec- 
tion on  the  anterior  face  of  a  Hodge  or 
Smith  pessary.  In  the  case  of  a  virgin  it 
is  often  difficult  to  withdraw  and  introduce 
these,  but  in  a  married  woman,  and  espe- 
cially in  a  parous  one,  it  is  easy  of  applica- 
tion. 

Another  instrument  which  I  employ  very  commonly,  both  in  antever- 
sion and  anteflexion,  is  that  shown  in  Figs.  159,  1  GO,  and  161. 

The  instrument  is  here  presented  closed.  It  is  introduced  open. 
Upon  pulling  upon  the  bow  which  presents  at  the  mouth  of  the  vagina, 
the  piece  which  sustains  the  uterus  falls  back,  and  it  can  readily  be  with- 
drawn by  patient  or  physician. 


Fig.  158. 


Thomas's  anteversion  pessary,  with 
fixed  projection. 


422 


ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


Fig.  162  represents  a  modification  of  the  two  instruments  which  pre- 
cede it. 


Fig.  159. 


Fig.  160. 


Fig.  161. 


Thomas's  anteversion  pessary 
as  it  appears  in  the  vagina. 


The  same  instrument 
in  position. 


The  same  instrument 
as  it  appears  on  removal. 


Fig.  163  represents  an  elastic  pessary  for  anterior  displacements,  made 
of  spiral  wire  and  strips  of  whalebone  covered  with  gutta-percha,  by  Otto 
and  Sons,  of  this  city.  The  whole  pessary  is  so  pliable  that  it  can  be  in- 
troduced and  withdrawn  with  perfect  ease. 


Fig.  162. 


Fig.  163. 


Thomas's  anteversion  and  anteflexion 
pessary. 


Thomas's  elastic  pessary  for  anterior 
displacements. 


If  the  attending  physician  possess  only  little  skill  in  the  use  of  pessa- 
ries, or  if  the  uterus  be  replaced  with  difficulty,  and  sustaining  it  appear 
to  require  force,  he  had  better  not  employ  an  internal  pessary,  but  limit 
himself  to  one  connecting  externally  with  a  band.  Support  may  be  given 
to  such  a  pessary  by  a  stem  arching  over  the  perineum,  as  shown  in  Fig. 
164.  This  displays  in  position  a  modification  of  Cutter's  retroversion 
pessary. 

The  upper  extremity  of  this  form  of  Cutter's  pessary  has  a  bulb  attached 
to  it,  and  is  so  bent  forwards  as  to  strike  the  base  of  the  bladder,  anterior 


PESSARIES.  423 


to  the  cervix.  This  is  introduced  by  the  practitioner,  and  its  method  of 
introduction  and  removal  fully  explained  to  the  patient.  She  is  instructed 
how  to  remove  it  upon  retiring  every  night,  and  to  replace  it  before  rising 
in  the  morning.     By  it  the  cervix  is  pulled  forwards,  the  utero-sacral  liga- 


Fig.  164. 


Anteversion  pessary  supporting  uterus. 

ments  stretched,  a  tolerance  of  a  foreign  body  established,  and  a  pouch  or 
pocket  created  anterior  to  the  cervix,  which  will  accommodate  in  time  the 
pessaries  already  depicted,  if  the  practitioner  desires  to  try  them.  The 
bulb  pessary  with  external  attachment  may  in  any  case  be  used  as  pre- 
paratory to  an  internal  instrument.     After  the  former  has  been  used  for  a 

Fig.  165.  Fig.  166. 


Cutter's  T  pessary  for  anterior  displacements.        Thomas's  modification  of  Cutter's  pessary. 

month  or  so,  the  latter  will  generally  be  applicable.  One  having  experi- 
ence with  these  two  instruments  can  almost  always  tell  without  experi- 
mentation which  will  be  appropriate.  If  there  be  a  pouch  anterior  to  the 
cervix  when  the  base  of  the  bladder   is  pressed  up  by  the  finger,  the  in- 


424 


ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


ternal  pessary  will  be  tolerated.  If  there  be  none,  and  the  tissue  resist 
pressure  by  the  finger,  it  cannot  be  employed  until  space  has  been  created 
by  the  other  instrument. 

To  facilitate  the  proper  introduction  of  this  instrument,  and  to  prevent 
the  supporting  portion  from  being  placed  behind  the  uterus  instead  of  in 
front  of  it,  Dr.  Cutter  has  devised  the  instrument  shown  in  Fig.  165,  and 
I  have  modified  it  as  shown  in  Fig.  166. 

Even  if  the  patient  made  an  effort  to  place  these  instruments  incorrectly, 
it  would  be  accomplished  with  difficulty.  Their  beneficial  results  in  these 
cases  are  unquestionable  except  by  those  whose  prejudices  or  incapacity 
have  defeated  them. 

Cases  will  occasionally  be  met  with  in  which  the  parts  are  so  sensitive 
that  the  hard  bulb  of  these  pessaries  cannot  be  borne.  Under  these  cir- 
cumstances, they  can  be  with  great  advantage  replaced  by  soft  balls  of 
very  fine  sponge,  until  the  reposition  of  the  uterus  and  removal  of  conges- 
tion which  is  thus  effected  render  solid  bulbs  tolerable. 

Fig.  167. 


Graily  Hewitt's  anteversion  pessary. 


Fig.  167  represents  the  very  excellent  pessary  of  Dr.  Graily  Hewitt. 
1  Lave  employed  it  very  extensively,  and  esteem  it  highly. 

I  have  also  in  some  cases  found  the  pessaries  of  Guerung  and  Fowler 
answer  very  well  in  anterior  displacements.  The  latter  of  these  is  shown 
in  Fig.  108. 


PESSARIES.  425 

He  who  expects  from  these  methods  extraordinary  results  will  surely 
be  disappointed.     In  a  certain  number  of  cases  failure  will    attend   all 
means  thus  far  devised,  not  excepting  surgi- 
cal  procedures.      My    experience,    however,  Fl°-  *G8. 
warrants  me  in  saying  that  a  persevering  re- 
sort to  the  treatment  here  advised  will  reward 
the  gynecologist  by  success  in  many  cases. 
After   overcoming    this    form    of   flexion,    a 
Meigs's  ring  pessary  should    be  worn  for  a 
long  time  to  prevent   relapse.     After  over- 

,i  •  i      it      ,i  <•  fn^ ■ ■.  Fowler's  pessarv  for  anterior 

coming  this,  and  all  other  iorms  of  flexion,  it  ,. ,      -     , 

"  *  displacements. 

is  well  to  dilate  the  cervical  canal  by  means 

of  graduated  sounds,  as  there  is  generally  more  or  less  contraction  of  it. 

I  would  especially  impress  the  importance  of  not  relying  exclusively 
upon  any  one  of  these  pessaries  or  internal  supporters.  Their  use  should 
be  combined  with  external  means  calculated  to  remove  pressure  from  the 
fundus.  By  this  combination  the  happiest  results  may  be  confidently 
anticipated  from  efforts  at  relief  of  this  often  distressing  accident. 

Before  concluding,  let  me  recapitulate  the  most  important  of  the  maxims 
embodied  in  this  chapter. 

1st.  Never  begin  treating  an  anteverted  uterus  mechanically  until  satis- 
fied that  no  periuterine  inflammation  exists ;  that  bad  symptoms  present 
are  due  to  the  displacement ;  and  that  no  condition  susceptible  of  removal 
by  medical  or  surgical  means  requires  earlier  and  more  prominent  atten- 
tion than  retention  of  the  uterus  in  position. 

2d.  Before  using  a  pessary,  act  thoroughly  on  the  intestinal  canal,  use 
warm  vaginal  injections  freely,  and  replace  the  uterus  repeatedly. 

3d.  Do  not  rely  upon  vaginal  support  alone,  but  aid  it  by  avoidance  of 
all  pressure  from  above,  and  by  using  an  abdominal  pad. 

4th.  Pessaries  are  of  the  greatest  value  in  treating  anteversion,  but 
require  much  more  skill,  are  attended  by  greater  danger,  and  are  more 
apt  to  need  frequent  alteration  than  when  used  in  posterior  displacements. 
There  is  no  comparison  in  the  relative  amount  of  difficulty  in  applying 
this  means  to  the  two  varieties  of  displacement. 

5th.  Never  use  an  anteversion  pessary  which  the  patient  cannot  remove, 
unless  she  keep  within  reach  of  your  aid ;  always  examine  frequently  to 
see  if  injury  is  being  done  to  the  vaginal  walls,  and  never  let  a  patient 
wearing  one  pass  entirely  out  of  observation. 

Gth.  If  no  sufficient  pouch  exist  anterior  to  the  cervix  for  the  accommo- 
dation of  an  internal  pessary,  create  one  by  use  of  the  external  bulb 
pessary. 

At  the  same  time  that  I  speak  so  strongly  of  the  difficulties  surrounding 
the  treatment  of  these  cases,  and  so  repeatedly  point  out  the  dangers 
attending  it,  I  must  make  this  statement  for  those  who  have  been  dis- 


426  ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

couraged  by  repeated  failures :  were  I  asked  from  the  treatment  of  what 
class  of  uterine  diseases  I  experienced  the  greatest  satisfaction,  and  felt 
that  I  had  accomplished  most  good  for  my  patients,  I  should  unhesitatingly 
reply — anterior  displacements  of  the  uterus. 

In  many  cases  of  this  variety  of  displacement,  a  great  deal  of  relief  may 
be  obtained  from  merely  lifting  up  the  displaced  organ  in  the  pelvis 
without  rectifying  the  anterior  displacement,  and  for  one  who  is  not 
familiar  with  the  use  of  anteversion  pessaries,  or  has  not  at  his  command 
facilities  for  procuring  good  instruments,  I  really  think  that  this,  in  the 
commencement  of  treatment,  if  not  throughout  its  entire  course,  is  the 
safer  and  better  plan.  Lifting  the  uterus  may  be  accomplished  by  the 
ordinary  ring  pessary  or  Gariel's  air  pessary,  and  the  simultaneous  use  of 
the  abdominal  pad  of  wood  or  cork.  If  the  pad  be  used  alone,  and  when 
the  fundus  uteri  is  behind  the  symphysis  pubis,  no  good  will  result  from 
it;  but  if  the  uterus  be  lifted  so  that  the  fundus  becomes  amenable  to 
direct  pressure,  the  benefit  felt  will  be  often  very  great. 

As  I  have  elsewhere  stated,  furnishing  support  to  a  uterus  anteriorly 
displaced  is  much  more  difficult  than  to  one  which  inclines  posteriorly. 
As  there  are,  therefore,  men  who  to-day  doubt  the  efficacy  of  support  for 
the  latter  forms  of  displacement,  there  must  be  many  more  who  entirely 
oppose  that  for  the  former.  To  both  classes  of  objectors  I  would  say, 
with  a  confidence  resulting  from  a  large  daily  experience,  that  the  hostility 
to  mechanical  support  in  both  varieties  of  displacement  arises  partly  from 
prejudice  and  partly  from  want  of  skill  on  the  part  of  the  practitioner, 
who  charges  to  the  mechanical  process  shortcomings  which  really  lie  at 
his  own  -door. 

On  more  than  one  occasion  I  have  heard  the  most  unmeasured  denun- 
ciations against  anteflexion  pessaries  upon  the  part  of  men  who  I  found 
had  been  persistently  using  them  upside  down.  Failing  to  give  relief  by 
instruments  thus  used,  the  illogical  experimenters  have  been  too  willing 
to  attribute  to  a  method  what  was  really  due  to  an  ignorant  abuse  of  it. 

In  certain  cases  of  anteflexion,  notably  those  requring  the  energetic 
means  recentlv  mentioned  for  their  reduction,  pessaries  resting  in  the 
vagina  fail  to  accomplish  the  required  purpose,  and  the  use  of  more  power- 
ful means  of  support  are  resorted  to. 

Recognizing  our  poverty  of  resources  in  such  cases  M.  Velpeau,1  be- 
tween thirty  and  forty  years  ago,  conceived  the  very  plausible  idea  of 
restoring  the  uterine  axis  to  its  normal  direction,  by  introducing  a  stem 
to  the  fundus,  and  retaining  it  there.  After  experiment  he  abandoned  it, 
and  subsequently  Amussat  followed  in  his  steps,  both  in  essaying  and  cast- 
ing it  aside.  In  1848,  Prof.  Simpson  again  brought  it  into  notice  in 
versions  and  flexions,  and  met  with  a  warm  ally  in  M.  Valleix,  of  Paris. 

1  Discussion  in  Acad,  de  Me"d.,  reported  in  Charleston  Med.  Journ.  1853. 


PESSARIES.  427 

The  instrument  known  as  the  intra-uterine  or  stem  pessary,  unquestion- 
ably counteracts  directly  and  immediately  all  flexions  of  the  uterus.  But 
it  was  found  to  cause  peritonitis  and  death  in  a  number  of  instances,  and 
in  consequence  it  was,  for  a  time,  almost  entirely  abandoned.  So  de- 
cidedly did  experience  appear  to  weigh  against  it  that  it  became  difficult 
to  explain  the  encomiums  once  showered  upon  it  by  its  advocates,  and  the 
remarkable  cures  reported  from  its  use.  Nonat  declared  that,  carried 
away  by  enthusiasm,  "  ils  se  sont  laisses  aller  trop  facilement  sur  le  terrain 
glissant  des  illusions."  Nevertheless,  the  method  was  never  entirely  cast 
aside,  for  none  could  hesitate  to  indorse  the  sentiment  expressed  by  Mal- 
gaigne,  in  the  discussion  upon  the  subject  in  the  Academy  of  Medicine  in 
Paris,  in  18")2,  that,  "  a  treatment  which  Amussat,  Velpeau,  Simpson, 
Huguier,  and  Valleix  had  tried,  cannot,  should  not,  be  considered  as 
repugnant  to  common  sense." 

During  the  last  ten  years  there  has  been  evidenced,  however,  a  growing 
inclination  to  return  to  this  plan,  and  the  last  five  have  brought  forth  a 
number  of  reports  favorable  to  it. 

At  a  medical  convention  held  in  Innsbruch,  Germany,  in  September, 
18G9,  this  subject  received  some  attention.  Spa?th,  of  Vienna,  expressed 
his  belief  in  the  disadvantages  of  the  intrauterine  treatment  of  flexions, 
although  he  has  found  in  some  cases  a  total  insensibility  and  an  absence 
of  reaction  from  the  wearing  of  intrauterine  instruments.  Ilugenberger, 
of  St.  Petersburg,  advocated  the  use  of  Simpson's  pessary  in  flexions,  and 
declared  his  experience  to  be,  that  it  was  not  only  tolerated,  but  did  great 
good  when  properly  applied  and  retained  for  a  sufficiently  long  time. 
More  recently,  Prof.  Schultze,  of  Jena,  advised  the  use  of  the  intraute- 
rine stem  in  certain  obstinate  cases,  but,  in  a  review  of  his  publication,  by 
Dr.  Munde,  in  the  American  Journal  of  Obstetrics,  it  evidently  appears 
that  he  does  so  with  caution  and  reserve. 

Prof.  Olshausen,  of  Halle,  likewise  published  his  experience  with  the 
method.  Of  its  character  the  reader  can  judge  for  himself,  for  the  pro- 
fessor gives  accurate  data.  Out  of  297  cases  of  versions  and  flexions,  81 
were  treated  by  the  stem  and  5  were  so  treated  for  other  conditions  than 
displacement.  Periuterine  inflammation  resulted  in  7  cases  ;  treatment 
was  stopped  on  account  of  hemorrhage  or  pain  10  times ;  the  stem  could 
not  be  kept  in  place  3  times.  Of  66  cases  in  which  they  did  well,  in  15 
the  results  appeared  to  be  permanent;  in  18  improvement  was  great  and 
lasted  a  long  time  ;  and  in  17  "  doubtful  permanent  results  were  obtained." 
In  11  sterility  was  cured.  The  stems  were  worn  for  periods  varying  from 
a  few  weeks  to  22^  months. 

Drs.  Savage  and  Chambers  have  both  reported  very  favorably  upon  this 
plan  in  the  Obstetrical  Journal  of  Great  Britain  and  Ireland,  to  which  the 
reader  is  referred  for  their  interesting  articles.     I  would  likewise  refer  to 


428 


ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


excellent  essays  by  Dr.  Routh1,  of  London,  and  Dr.  Van  De  Warker,1  of 
Syracuse. 

Before  the  use  of  this  method  careful  examination  should  be  made  as 
to  the  previous  existence  of  periuterine  inflammation.  If  any  be  found 
existing  the  uterine  stem  should  be  avoided. 

A  great  variety  of  instruments  have  been  employed  for  keeping  the 
stem  in  place.  Some  are  complicated,  others  stiff  and  unyielding,  while 
most  are  not  susceptible  of  removal  by  the  patient,  and  are  therefore 
wanting  in  the  main  element  of  safety.  I  would  recommend  the  instru- 
ment which  I  employ  for  this  purpose  as  not  subject  to  any  of  these  objec- 
tions. It  consists  of  two  parts,  a  stem  of  solid  glass,  two  to  two  and  a 
half  inches  long,  and  ending  below  in  a  round  bulb  as  represented  in  Fig. 
1G9.  This  being  introduced  into  the  uterus,  it  is  supported  by  the  ante- 
flexion pessary  shown  in  Fig.  1G9,  or,  if  difficulty  be  found  in  using  this, 
by  an  ordinary  Hodge  pessary,  between  the  branches  of  which  a  cup  has 
been  placed,  as  shown  in  Fig.  197,  or  by  a  disk  of  vulcanite  shaped  like 
the  Hodge  or  Smith  pessary,  as  shown  in  Fig.  170. 


Fig.  1(59. 


Fig.  170. 


Anteflexion  pessary  supporting  intra-nterine  stem.  Glass  stem  supported  by  disc  pessary. 

The  stem  ending  in  a  round  bulb  rests  upon  the  surface  of  the  pessary, 
and  changes  position  with  every  movement  of  the  uterus.  It  must  be  re- 
membered that  it  is  not  used  for  anteversion  but  for  anteflexion,  and  that 
stability  of  the  base  of  the  stem  is  not  desirable.  Just  above  the  shoulder 
a  small  hole  may  be  made  through  the  stem  through  which  a  silk  thread 
is  passed  which  hangs  from  the  vulva.  Upon  the  first  evidence  of  trouble 
the  patient  draws  out  the  loosely  fitting  pessary,  then  making  traction  upon 
the  thread  removes  the  stem. 

Before  introduction  of  the  stem,  the  cervix,  if  found  to  be  too  contracted 
for  it  to  pass,  should  be  dilated  by  one  or  more  tents,  which  for  the  time 
straighten  the  uterus  and  dilate  the  cervical  canal.  After  introduction  the 
patient  should  be  kept  in  bed  for  three  or  four  days,  and,  upon  leaving  it, 
should  be  careful  in  her  movements  for  a  week  or  two.     She  should  be 


1  London  Obstet.  Trans. 


2  Amer.  Gynecolog.  Trans. 


TREATMENT.  420 

directed  to  remove  the  tent  upon  the  occurrence  of  pain,  chilliness,  or  feel- 
ing of  general  languor  or  discomfort.  Even  the  most  ardent  advocates  of 
stem  pessaries  will  admit  the  propriety  of  these  precautions,  and  even  their 
bitterest  opponents  must  allow  that  with  them  as  a  safeguard,  in  certain 
cases  they  should  he  resorted  to.  To  cast  them  entirely  aside  when  such 
high  authority  recommends  them,  would  be  irrational  and  unjustifiable. 
To  use  them  freely  in  the  face  of  such  evidence  as  we  possess  would  be 
reckless  and  unwarrantable. 

It  requires  skill  in  introducing  the  pessary  after  introduction  of  the 
stem  before  the  latter  falls  from  its  place.  A  Sims's  speculum  is  a  sine  qua 
non  ;  the  stem  should  be  held  in  place  by  Sims's  depressor,  and  the  pessary 
be  slid  into  place  upon  this.     In  this  way  the  manoeuvre  is  easy. 

I  am  opposed  to  the  exhibition  of  instruments  which  I  have  not  myself 
fully  tried,  but  tlie  stem  pessary  of  Dr.  H.  F.  Campbell  impresses  me  so 
favorably  that  I  depart  from  my  rule  and  present  it  here. 

Fig.  171. 


Campbell's  soft-rubber  spring-stem  pessary.     A.  The  soft-robber  stem  and  spring  prepared  for 
introduction.     B.  Shows  tlie  spring  separately.     C.  The  rubber  cap  or  hood. 

It  will  be  seen  that  this  consists  of  a  soft-rubber  tube  and  watch-spring. 
It  is  introduced  bent  upon  itself  by  means  of  a  sound,  and  this  being  with- 
drawn it  straightens  itself  under  the  influence  of  the  protected  spring. 

But  in  a  certain  number  of  cases  even  the  intra-uterine  stem  fails.  Then 
the  gynecological  surgeon,  following  the  example  of  the  general  surgeon, 
gives  up  striving  after  an  end  unattainable  by  minor  means,  and  resorts 
to  the  knife  for  relief. 

Should  the  patient  not  tolerate  the  intra-uterine  pessary  with  comfort, 
should  the  flexion  not  yield  to  the  treatment  by  it,  or  should  the  practi- 
tioner prefer  to  adopt  operative  procedures,  an  operation  devised  by  Sims 
is  at  his  disposal  not  intended  to  cure  the  displacement,  but  to  remedy  its 
resulting  cervical  obstruction,  leaving  the  disorder  of  position  unchanged. 

Operation  for  Irreducible  Cervical,  Corporeal,  or  Cervico- Corporeal 
Flexion. — If  a  piece  of  stiff  tubing  be  bent,  the  calibre  of  its  canal  will  be 
obliterated  at  the  point  of  flexure  in  proportion  to  the  acuteness  of  the 
angle  created.  In  the  same  manner  is  the  uterine  canal  affected  by  the 
lesion  under  consideration.  The  obstruction  created  in  this  way  prevents 
the  free  escape  of  menstrual  blood,  which  distends  the  cavity  of  the  uterus 
and  forms  clots  within  it,  and  these  at  each  menstrual  period  are  expelled 


430 


ANTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


Fig.  172. 


by  uterine  tenesmus.  In  consequence  of  this,  inflammation  of  the  mucous 
lining  of  the  uterus  arises,  that  in  time  may  produce  areolar  hyperplasia, 
which  favors  further  displacement  by  the  increase  of  uterine  weight  attend- 
ing it.  The  effort  required  for  expelling  clotted  menstrual  blood  creates 
painful  menstruation,  and  the  same  obstruction  which  retards  egress  of 
fluids  interferes  with  ingress  and  prevents  conception. 

Having  been  forced  to  accept  the  displacement  as  an  irremediable  evil, 
we  now  endeavor  to  strike  at  one  of  the  sources  of  the  pathological  series 
which  results  from  it  by  overcoming  obstruction  at  the  point  of  flexure  ;  in 
other  words,  by  substituting  a  straight  for  a  crooked  canal.     This  can  be 

accomplished  by  cutting  through  one 
wall  of  the  cervix.  Having  thus  over- 
come cervical  obstruction  and  consequent 
accumulation  of  fluids  in  utero,  do  we  at 
the  same  time  remove  the  tendency  to 
mechanical  congestion  of  the  body  of  the 
uterus  ?  Not  entirely,  but  if  we  secure 
the  results  of  cervical  section  as  we  may 
ordinarily  do  by  subsequent  use  of  the 
intra-uterine  stem,  we  accomplish  to  a 
certain  extent  both  results. 

If  the  posterior  uterine  wall,  bent  for- 
ward as  shown  by  the  line  c  b,  Fig.  172, 
in  a  case  of  anteflexion,  be  cut  towards 
the  vaginal  junction  so  that  a  probe  will 
pass  into  the  uterus  in  the  direction  of 
the  line  a  d,  the  obstruction  resulting 
from  the  existence  of  an  angle  will  be 
removed,  and  thus  fluids  would  have  free 
entrance  and  exit,  for  instead  of  turning 
the  angle  at  b  and  escaping  at  c,  they 
would  at  once  escape  at  b. 

The  operation  which  accomplishes  this 
result  is  an  exceedingly  simple  one,  and  is  thus  performed.  The  patient 
being  placed  in  position,  and  Sims's  speculum  introduced,  the  cervix  is 
seized  and  drawn  down  by  a  tenaculum.  Then,  by  a  long  slender  knife, 
that  of  Sims's  is  the  best,  an  incision  is  made  as  far  as  can  be  conveniently 
done  without  involving  the  vaginal  junction,  which  will  probably  be  above 
the  point  b  in  Fig.  172.  The  blade  of  Sims's  knife,  represented  in  Fig. 
173,  is  now  introduced  through  the  os  internum,  and  the  tissues  are  cut 
so  as  to  lay  open  the  posterior  wall  of  the  cervix.  A  little  shoulder  will, 
as  Dr.  Emmet  has  pointed  out,  be  generally  found  to  exist  on  the  anterior 
wall  of  the  canal,  just  at  the  angle  made  by  flexure  of  this  wall.  Towards 
this  the  blade  of  the  knife  should  now  be  turned,  and  it  should  be  cut 
through. 


Schematic  diagram,  showing  the  crea- 
tion of  new  uterine  axis,  a  b  represents 
the  axis  of  the  body;  b  c  represents  the 
axis  of  the  neck  :  b  d  represents  the  axis 
created  by  incision. 


TREATMENT, 
Flo.  173. 


431 


Sims's  knife. 


In  this  operation  the  knife  alone  should  be  used.     None  of  the  utero- 
tomes  are  at  all  appropriate.     Just  after  the  operation  the  glass  stem 

Fig.  174. 


Posterior  section  of  the  cervix.     (Sims.) 

shown  in  Fig.  170  should  be  introduced  so  as  to  occupy  the  whole  cervix 
from  os  internum  to  os  externum.  Under  this  a  firm  tampon  of  wet  car- 
bolized  cotton  should  be  placed.  In  forty-eight  hours  the  tampon  should  be 
removed,  and,  if  any  sign  of  hemorrhage  be  present,  reapplied.  If  not, 
one  of  the  sustaining  pessaries  shown  in  Figs.  169,  170,  or  197  should  be 
introduced,  the  vagina  be  thoroughly  syringed  with  warm  carbolized  water 
twice  daily,  and  the  patient  be  kept  in  bed  for  a  fortnight.  The  stem  and 
pessary  should  be  worn,  if  no  evil  symptoms  develop,  for  two  or  three 
months.  Then,  after  cicatrization  has  fully  occurred,  they  may  be  removed 
with  a  reasonable  hope  that  the  canal  will  remain  pervious. 

Success  in  this  operation  depends  less  on  its  method  of  performance 
than  on  the  persistent  wearing  of  the  glass  stem  until  cicatrization  has 
been  fully  accomplished. 

Should  an  error  be  made  as  to  the  etiology  of  the  displacement  or  the 
recognition  of  its  complications,  and  this  apparently  trifling  operation  be 
performed  during  the  existence  of  periuterine  cellulitis  or  peritonitis,  the- 
gravest  results  may  follow,  and  the  sufferings  of  the  patient  be  greatly 
aggravated.  Indeed,  had  all  the  fatal  cases  which  have  occurred  in  con- 
sequence of  this  operation  been  published  to  the  profession,  as  they  should 


432     POSTERIOR  DISPLACEMENTS  OF  THE  UTERUS. 

have  been,  the  list  would,  I  think,  be  a  startling  one.  I  myself  know  of 
several,  and  have  heard  rumors  of  many  others.  It  may  be  asked  why 
this  operation  upon  a  part  of  the  uterus  which  does  not  ordinarily  resent 
surgical  interference  should  so  often  be  followed  by  dangerous  conse- 
quences. My  conviction  is,  that  the  operation  per  se  is  not  attended  by 
great  danger.  It  is  the  performance  of  it  when  pelvic  peritonitis  exists  in 
chronic  form  that  has  caused  it  to  produce  such  bad  results.  Even  a 
minor  operation,  performed  in  the  face  of  a  condition  which  should  inter- 
dict the  use  of  the  uterine  probe,  may  set  up  a  train  of  symptoms  which 
may  lead  to  a  fatal  issue. 

After  these  procedures  for  the  cure  of  anteflexion  which  has  for  a  long 
time  been  irreducible  and  was  very  probably  congenital,  conception  is  by 
no  means  common.  Operations  for  this  condition  often  effect  relief  of 
menstrual  and  amelioration  of  circulatory  disorders;  and  they  may  even 
cure  sterility,  but  he  who  practises  them  should  beware  how  he  makes 
promises  to  this  effect. 

It  is  very  evident  that  at  present  a  formidable  wave  of  professional 
opinion  is  steadily  advancing  in  opposition  to  this  operation.  Some  of  the 
very  men  who  took  exaggerated  positions  in  reference  to  its  value  ten 
years  ago  are  now  emphatic  in  its  denunciation.  It  is  the  old  story  of  the 
swing  of  the  pendulum  !  The  operation  should  hold  to-day  just  the  posi- 
tion to  which  it  was  entitled  ten  years  ago.  Its  merits  are  unquestiona- 
ble ;  its  place  cannot  in  the  interests  of  gynecology  be  left  vacant.  But  as 
it  did  not  deserve  the  encomiums  of  a  former  time,  so  it  does  not  merit 
the  depreciation  which  is  aimed  at  it  to-day. 

One  of  its  advantages  has  been,  I  think,  lost  sight  of.  Many  cases  of 
obstructive  dysmenorrhea,  sterility,  and  inefficient  menstruation,  for  which 
resort  has  been  had  to  it  with  good  effect,  are  due  to  an  undeveloped  state 
of  the  cervix,  which,  compared  with  the  body  of  the  uterus,  is  dispropor- 
tionately small.  Section,  followed  by  the  use  of  the  glass  cervical  plug 
for  two  or  three  months,  will  often  improve  the  nutrition  of  the  cervix 
and  result  in  its  increased  development. 


CHAPTER    XXVIII. 

POSTERIOR  DISPLACEMENTS  OF  THE  UTERUS. 

Retroversion  and  Retroflexion. 

Definition  and  Frequency Retroversion  consists  in  a  posterior  incli- 
nation of  the  uterus,  so  that  the  fundus  approaches  the  sacrum  and  the 
cervix  advances  towards  the  symphysis  pubis.  As  an  idiopathic  primary 
lesion,  it  is  not  common,  but  it   is  frequently  symptomatic  of  neoplasms, 


RETROVERSION  AND  RETROFLEXION. 


133 


areolar   hyperplasia,   or  other  states  which  increase   the   weight   of   the 

uterus. 

Fir..  175. 


Retroversion  of  the  uterus. 

Retroflexion  is  said  to  exist  when  the  body  of  the  uterus  is  bent  towards 
the  sacrum  so  as  to  create  an  angle  on  the  posterior  wall. 

Fig.  176. 


28 


Retroflexion 


434     POSTERIOR  DISPLACEMENTS  OF  THE  UTERUS. 

Predisposing  Causes. — The  predisposing  causes  of  posterior  displace- 
ments are  parturition,  general  muscular  debility,  and  habits  of  indolence 
and  inactivity. 

Exciting  Causes These  may  be  classified  under  four  heads  : — 

Influences  increasing  uterine  weight. 

Fibroids ; 

Subinvolution  ; 

Areolar  hyperplasia ; 

Pregnancy ; 

Congestion. 
Influences  dragging  the  uterus  out  of  place. 

Adhesions  from  pelvic  peritonitis  or  periuterine  cellulitis  ; 

Rectocele  ; 

Subinvolution  of  the  vagina  ; 

Prolapsus  of  posterior  vaginal  wall ; 

Retroflexion. 
Influences  forcibly  displacing  the  uterus  by  direct  pressure. 

Severe  succussion  by  blows  or  falls  ; 

Muscular  efforts  ; 

Distended  bladder ; 

Tumors ; 

Tight  bandaging  after  parturition  ; 

Tight  and  heavy  clothing. 
Influences  weakening  uterine  supports. 

Parturition ; 

Destruction  of  power  of  perineum  ; 

Prolapse  of  vagina. 
Of  all  these  causes  the  two  most  frequent  are  decidedly  prolapse  of  the 
vagina,  from  subinvolution  or  ruptured  perineum  ;  and  areolar  hyperplasia, 
commonly  the  advanced  stage  of  subinvolution  of  the  uterus.  All  the 
others  mentioned  are  sometimes  met  with,  but,  compared  with  these,  they 
are  insignificant  as  causes. 

As  might  be  presumed  from  the  natural  obliquity  of  the  uterus,  ante- 
rior displacements  not  unfrequently  occur  as  idiopathic  lesions  resulting 
from  pressure  of  superincumbent  viscera  forced  down  upon  the  fundus  by 
tight  clothing  or  muscular  efforts.  Retroversion  occurs  in  this  way  less 
frequently.  It  generally  depends  upon  some  pathological  state  in  the 
uterus  or  its  appendages.  The  third  class  of  causes  mentioned  as  dis- 
placing the  organ  by  direct  pressure  may  act  through  violent  succussion, 
and  induce  sudden  displacement  with  symptoms  of  most  urgent  character. 
Prolonged  pressure  from  a  distended  bladder,  or  from  a  tumor  anterior  to 
or  above  the  uterus,  may  likewise  induce  gradual  displacement.  A  little 
reflection  will  explain  how  the  management  of  parturient  women,  by 
British  and  American  practitioners  at  least,  favors  the  occurrence  of  the 


VARIETIES    OF    RETROVERSION.  435 

accident.  In  the  first  place,  it  must  be  remembered  that  pregnancy  coin- 
bines  in  itself  two  of  the  influences  which  are  productive  of  this  condition, 
increase  of  uterine  weight  and  relaxation  of  supports.  It  is  no  exaggera- 
tion to  assert  that  the  usual  plan  of  management  alter  parturition  supplies 
one  of  the  others  which  are  mentioned  above.  Tlie  woman  lying  almost 
constantly  upon  her  back,  the  heavy  fundus  naturally  tends  to  fall  back- 
wards into  the  hollow  of  the  sacrum.  Many  nurses  insist  upon  this  posi- 
tion, and  often  for  days  refuse  the  patient  the  privilege  of  lying  upon  the 
side.  But  this  is  not  all,  many  a  nurse's  reputation  among  ladies  rests 
upon  her  capacity  for  "  preserving  the  figure"  by  tight  bandaging.  A 
powerful  woman  will  often  expend  her  whole  force  in  making  the  bandage 
as  tight  as  possible  to  accomplish  this  purpose.  No  one  who  has  watched 
the  process  can  doubt  its  influence  in  displacing  the  uterus  by  direct  pres- 
sure. There  is  no  practice  connected  with  the  lying-in  room  to  which  so 
much  of  almost  superstition  attaches  as  to  the  use  of  the  obstetric  bandage 
for  preservation  of  the  figure  and  prevention  of  hemorrhage.  This  is  a 
repetition  of  what  I  have  elsewhere  stated,  but  the  importance  of  the  sub- 
ject in  my  mind  must  be  my  excuse  for  dwelling  upon  it  here. 

If  involution  have  gone  on  tardily  and  imperfectly,  the  woman  is  still 
more  prone  to  have  the  uterus  forced  backwards.  The  round  ligaments, 
which  are  composed  of  muscular  structure  similar  to  that  of  the  uterus, 
are  important  agents  in  preventing-  this.  It  is  highly  probable  that  an 
arrest  of  retrograde  metamorphosis  affecting  the  uterus  may  likewise  affect 
them,  and  leave  them  longer  and  less  powerful  than  natural.  "  Hyper- 
trophy of  the  two  (round)  ligaments,"  says  Scanzoni,1  "  constantly  accom- 
panies a  natural  pregnancy ;  while,  as  we  have  ourselves  had  an  oppor- 
tunity to  determine,  in  the  case  of  a  bicorned  uterus,  biparted,  or  bilocular, 
the  ligament  corresponding  to  the  side  on  which  was  the  pregnancy,  was 
alone  hypertrophied.  .  .  .  We  remember  many  cases  of  women  who 
have  died  after  metritis  or  puerperal  peritonitis,  with  whom  one  or  both 
of  the  round  ligaments  were  notably  hypertrophied,  and  presented  a  lively 
red  color,  with  a  serous  infiltration." 

Not  only  as  a  result  of  pregnancy  do  these  ligaments  develop  a  condi- 
tion which  renders  them  prone  to  yield  to  traction  from  an  enlarged  uterus 
— Boivin  and  Duges  have  observed  hypertrophy  in  them,  with  dilatation 
of  their  vessels  from  chronic  engorgement,  fibroids,  and  even  from  ova- 
rian tumors. 

Varieties  of  Retroversion Retroversion  may  exist  in  slight  degree,  the 

uterine  axis  inclining  so  as  to  make  with  that  of  the  superior  strait  an  angle 
of  45°  ;  or  it  may  incline  to  90°,  thus  lying  across  the  pelvis  ;  or  the  cervix 
may  be  thrown  up  and  the  fundus  descend  so  as  to  form  an  angle  of  135°. 

•  Scanzoni,  op.  cit.,  p.  358. 


436 


POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


These  varieties  constitute  the  first,  second,  and  third  degrees  of  retro- 
version. 

Retroflexion  also  has  been  divided  into  varieties  dependent  upon  the 
degree  of  intensity,  but  these  are  so  entirely  arbitrary  that  they  may  as 
well  be  ignored. 

Fig.  177. 


The  degrees  of  retroversion. 


Symptoms. — Posterior  displacements  produce  annoying  symptoms  by 
creating  congestion  of  the  uterine  body,  obstructing  the  cervical  canal, 
and  causing  pressure  on  the  rectum,  congestion  of  the  ovaries,  and  reflex 
nervous  manifestations.  Through  so  many  avenues  of  approach  it  may 
well  be  supposed  that  the  symptoms  are  numerous.  They  are  usually  as 
follows  : — 

Severe  backache  ; 

Weight  in  rectum  with  tesnesmus; 

Leucorrhoea  ; 

Dysmenorrhea ; 

Nervous  disturbances  ; 

Difficult  locomotion  ; 

Menorrhagia ; 

Tendency  to  abortion  ; 

Pain  on  sexual  intercourse  ; 

Pelvic  neuralgia ; 

Epigastric  depression  ; 


PHYSICAL    SIGNS — DIFFERENTIATION.  437 

Gastric  derangement; 

Uterine  colic  or  tenesmus  ; 
Sterility. 
Many  of  these  symptoms  produce  epiphenomona  of  their  own,  and   thus 
increase  a  list  which  is  already  long. 

Physical  Siyns The  diagnosis  is  made  by  the  following  means  : — 

Vaginal  touch  ; 
Conjoined  manipulation  ; 
Rectal  touch ; 
The  uterine  probe. 
The  patient   lying  on   the  back,  the  index   finger  is   introduced  to  the 
cervix,  which  is  found  in  its  normal  place.     It  is  then  swept  over  the  base 
of  the  bladder,  where  nothing  abnormal   is  observed.     Then  it  is  passed 
into  the  fornix  vaginae,  and  here  a  round  tumor  continuous  with  the  ridge 
of  the  cervix  is  discovered.     The  disengaged   hand  is  then  placed  on  the 
abdomen,  and  made  to  approximate  the  finger  in  the  vagina,  so  as  to  grasp 
the  body  of  the  uterus.     If  the  abdominal  walls  be   lax,  this  will  yield 
good  results,  but  not  otherwise.     The  finger  should  now  be  carried  into 
the  rectum,  in  order  to  study  further  the  character  of  the  tumor  pressing 
upon  this  canal.     The  patient  being  then  placed  upon  her  side  and  the 
speculum  introduced,  the  uterine  probe,  which  has  been  curved  in  accord- 
ance with  the  direction  impressed  on  the  mind  by  the  sense  of  touch,  is 
gently  passed  into  the  uterine  cavity  to  the  fundus,  which  completes  the 
diagnosis. 

Differentiation — This  displacement  may  be  confounded  with  fecal  im- 
paction, fibrous  tumors,  cellulitis  or  peritonitis,  extra-uterine  gestation,  a 
prolapsed  and  enlarged  ovary,  and  prolapsed  kidney.  The  careful  practice 
of  the  four  diagnostic  methods  mentioned  will  remove  all  doubts. 

In  certain  very  rare  cases  the  kidney  has  been  known  to  prolapse  into 
Douglas's  cul-de-sac  and  produce  the  most  anomalous  symptoms.  In  a 
case  of  my  own  in  which  a  very  obscure  tumor  existed  posterior  to  the 
uterus,  this  diagnosis  was  made  by  Dr.  Noeggerath  in  consultation.  In 
accordance  with  his  advice  I  placed  the  patient  in  the  knee-chest  position, 
and  applied  a  good  deal  of  upward  pressure,  when  the  tumor  suddenly 
escaped  into  the  abdomen.  Support  was  given  by  a  bulb  pessary,  and  for 
a  time  my  patient  was  relieved,  but  upon  her  return  to  her  home  in  Vir- 
ginia a  complete  relapse  occurred.  Dr.  Noeggerath  tells  me  that  he  has 
met  with  but  one  other  such  case.  Of  course  the  correctness  of  the  diag- 
nosis is  doubtful.  I  am  inclined  to  admit  it  from  the  peculiar  symptoms 
exhibited,  and  by  the  fact  that  post-mortem  examination  proves  that  such 
a  prolapse  of  a  floating  kidney  sometimes  occurs.  The  following  account 
of  such  a  case  may  be  found  in  Braithwaite's  Retrospect. 

"  Examining  the  body  of  a  man  who  had  died  of  phthisis,  aged  thirty-five, 
Dr.  Isaacs  found  the  left  kidney  located  in  the  pelvis,  its  upper  end  being  in 


438  POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

contact  with  the  bifurcation  of  the  aorta,  and  its  lower  touching  the  poste- 
rior surface  of  the  bladder,  and  lying  on  the  fifth  lumbar  vertebra,  and  first, 
second,  and  third  pieces  of  the  sacrum.  Its  right  edge  was  in  contact  with 
the  rectum,  and  the  left  with  the  iliac  portion  of  the  brim  of  the  pelvis. 
There  were  three  renal  arteries,  one  coming  from  the  aorta,  and  two  others 
from  the  right  common  iliac.  The  kidney  was  of  the  ordinary  size,  but  the 
supra-renal  capsule  was  twice  its  natural  size,  and  of  the  shape  of  a  fig-leaf, 
and  it  occupied  its  normal  position  in  the  lumbar  region." 

Consequences  of  Posterior  Displacements. — The  post-uterine  peritoneal 
space  being  much  more  extensive  than  the  anterior,  they  proceed  to  a  more 
aggravated  degree  than  anterior  displacements.  The  body  sometimes  de- 
scends to  the  upper  extremity  of  the  vagina,  and  instances  are  recorded 
by  Rokitansky  and  Schott  in  which  it  penetrated  the  walls  of  the  rec- 
tum and  vagina,  and  forced  itself  into  these  canals.  This  of  course  is  a 
very  rare  occurrence,  but  it  is  worthy  of  mention  as  showing  how  great  is 
the  pressure  which  a  re.troflexed  uterus  may  exert.  The  ordinary  conse- 
quences of  the  affection  are — 

Dysmenorrhea  ; 

Endometritis  ; 

Sterility ; 

Areolar  hyperplasia  ; 

Pelvic  peritonitis. 
As  rare  complications  may  also  be  recorded,  hematometra  and  hydro- 
metra  from  imprisonment  of  fluids  by  obliteration  of  the  canal  by  flexure 
at  the  os  internum.  Should  pregnancy  occur  during  the  existence  of  this 
deviation,  or  retroflexion  complicate  pregnancy,  and  the  fundus  be  incar- 
cerated below  the  promontory  of  the  sacrum,  abortion  will  result.  This 
cause  of  that  accident  is  so  very  common  that  it  should  be  suspected  and 
examined  for  in  every  case  of  habitual  abortion. 

Prognosis There  are  three  conditions  which  render  the  prognosis  of 

this  condition  unfavorable  :  where  the  uterus  is  bound  down  by  strong  ad- 
hesions ;  where  the  organ  contains  in  its  parenchyma  a  fibrous  tumor;  and 
where  the  vagina  is  attached  to  the  cervix  so  near  the  external  os  that  no 
pessary  can  rest  posterior  to  the  cervix  to  sustain  the  uterus  after  it  is  re- 
placed. This  form  of  utero-vaginal  junction  is  important  as  giving  ground 
for  a  very  grave  prognosis  as  to  the  cure  of  all  anterior  and  posterior  dis- 
placements. 

Treatment.— The  first  indication  is  to  restore  the  uterus  to  its  place,  the 
second  to  prevent  its  again  becoming  displaced. 

Methods  of  Reduction In  an  ordinary  case  in  which  the  uterus  is  not 

firmly  held  in  retroversion  by  the  surrounding  parts,  the  patient  should 
be  placed  on  the  left  side  as  for  an  ordinary  examination  with  Sims's 
speculum.  The  operator  then  lubricating  the  index  and  middle  finger  of 
the   right  hand   introduces   them,  he  standing  at  the  patient's  back,  and 


METHODS    OF    REDUCTION.  439 

facing  her  head,  and  the  palmar  surfaces  of  the  fingers  being  directed  to 
the  rectum.  The  body  of  the  uterus  is  then  lifted  upon  the  tips  of  the 
fingers  until  it  becomes  erect,  then  their  dorsal  surfaces,  which  will  really 
be  the  backs  of  the  nails,  are  made  to  push  the  organ  over  into  normal 
position.  As  the  uterus  becomes  elevated  the  middle  finger  is  still  kept  in 
the  post-uterine  space  to  maintain  what  is  gained,  while  the  index  finger 
is  carried  in  front  of  the  cervix,  and  this  part  is  by  pressure  forced  back 
towards  the  sacrum.  The  middle  finger  is  now  likewise  placed  in  front 
of  the  cervix,  and  by  both  fingers  this  part  is  forced  towards  the  sacrum 
and  kept  there  for  a  short  time.  This  method  of  replacing  a  uterus  which 
has  fallen  backwards  is  superior  to  any  other  that  I  know  of.  I  would 
urge  a  trial  of  it  exactly  as  here  described,  and  will  answer  for  its  effi- 
ciency. 

But  sometimes  the  uterus  is  irreducible  by  any  but  the  most  powerful 
methods.  In  such  a  case,  the  bladder  and  rectum  having  been  evacuated, 
and  the  clothing  loosened,  the  patient  is  made  to  kneel  upon  a  hard  sur- 
face, and  to  place  the  sternum  as  closely  as  possible  in  contact  with  the 
plane  which  supports  her.  The  practitioner  then  lubricating  two  fingers 
of  the  right  hand  carries  them  into  the  vagina  and  against  the  fundus. 
He  then  directs  the  patient  to  fill  the  chest  with  air,  and  expel  it  com- 
pletely. As  she  does  so,  he  forcibly  elevates  the  fundus  and  restores  it  to 
its  place.  Should  this  plan  fail,  the  buttocks  should  be  still  more  elevated 
by  placing  cushions  under  the  knees,  and  the  attempt  repeated  with  two 
fingers  in  the  rectum  instead  of  in  the  vagina. 

Should  these  powerful  and  usually  efficient  methods  fail,  I  would  strongly 
urge  against  efforts  being  made  by  introduction  into  the  uterus  of  instru- 
ments for  restitution.  If  they  exert  less  force,  they  will  not  be  effectual ; 
if  more,  they  may  penetrate  the  uterus  and  create  peritonitis.  Besides, 
in  a  case  resisting  the  plan  detailed,  there  will  probably  be  found  to  be 
adhesions  as  the  source  of  the  difficulty.  Under  these  circumstances, 
Kuchenmeister1  has,  from  extended  experience,  advised  the  introduction 
of  the  colpeurynter  filled  with  water  every  day,  for  as  long  a  time  as  the 
patient  can  bear  it.  Steady  hydrostatic  pressure  often  in  this  way  accom- 
plishes safely  what  sudden  force  would  do  with  danger  to  the  patient. 

In  cases  requiring  the  application  of  much  less  force,  Sims's  repositor 
is  an  excellent  instrument  for  the  purpose,  and  should  be  employed.  This 
instrument,  which  is  represented  by  Fig.  178,  consists  of  a  short  metal 
sound,  terminating  in  a  ball.  The  ball  is  clasped  by  a  straight  shaft, 
moves  upon  a  pivot  running  through  its  centre,  and  is  perforated  by 
seven  holes.  Through  the  shaft  runs  a  rod  which  is  projected  by  a  con- 
cealed spring,  that  is  governed  by  the  finger  passed  through  the  ring. 
The  ball  can  be  made  to  revolve  so  that  the  sound  describes  a  half  circle, 

1  Am.  Journ.  Med.  Sci.,  July,  1870,  p.  275. 


440  POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

by  withdrawing  the  stop-rod  which  runs  through  the  shaft,  and  depressing 
the  instrument. 

Fig.  178. 


Sims's  uterine  repositor. 

In  the  majority  of  instances  reposition  is  perfectly  practicable  by  eom- 
joined  manipulation  or  rectal  taxis,  or  by  means  of  a  sponge  fixed  in  a 
sponge-holder  and  pressed  into  the  fornix  vaginae. 

Good  results  will  often  attend  carrying  one  sponge  staff  up  the  rectum 
and  another  up  the  vagina,  so  as  to  make  pressure  upon  the  displaced 
fundus,  after  the  plan  adopted  by  Dr.  Bond,  of  Philadelphia,  in  his 
ingenious  repositor,  which  is  represented  in  Prof.  Meigs's  work  on  Mid- 
wifery. In  replacing  a  uterus  in  this  or  any  other  malposition,  the 
operator  should  never  forget  that  inflammatory  action  may  have  caused 
an  effusion  of  lymph  around  it  which  resists  its  removal,  and  that  if  these 
adhesions  be  violently  ruptured  cellulitis  or  peritonitis  may  result. 

As  early  as  1820,  von  Ritgen,  of  Giessen,  recommended  the  knee- 
chest  position  for  the  automatic  replacement  of  the  retroflexed  womb,  and 
since  his  time  the  method  has  been  often  resorted  to  as  an  adjuvant  to 
replacement.  To  Dr.  H.  F.  Campbell,  however,  belongs  the  credit  of 
systematizing  it  as  a  method  of  "  pneumatic  self-replacement,"  and  put- 
ting it  at  the  disposal  of  the  gynecologist  for  daily  use.  "  Campbell's 
method"  never  does  harm,  generally  effects  great  good  as  an  adjuvant 
to  other  treatment,  and  in  rare  cases  proves  in  itself  sufficient  for 
complete  relief.  It  consists  simply  in  the  reversal  of  gravity  by  placing 
the  patient  in  the  attitude  represented  in  Figs.  179  and  180,  an  examina- 
tion of  which  will  at  once  show  the  action  of  the  method  upon  intestines 
and  uterus.  Dr.  Campbell  likewise  directs  that  a  small  glass  tube,  about 
as  large  as  the  largest  sized  test-tube,  should  be  introduced  into  the  vagina 
by  the  patient  while  in  the  "  genu-pectoral "  position,  to  secure  the  admis- 
sion of  air  and  its  action  as  a  repositor. 

During  the  treatment  of  all  uterine  displacements,  except  inversion  and 
irreducible  flexion,  the  patient  may,  with  advantage,  be  directed  to  prac- 
tise this  automatic  method  of  replacement  for  five  or  ten  minutes  upon 
retiring  at  night  and  upon  rising  in  the  morning.  If  a  pessary  be  worn, 
it  will  be,  by  this  plan,  relieved  of  much  of  the  pressure  which  it  bears, 
congestion  of  the  pelvic  viscera  will  be  lessened,  and  the  organs  of  the 
abdomen,  being  displaced  upwards,  will  not  immediately  descend  and  de- 
press those  of  the  pelvis. 


METHODS    OF    REDUCTION. 
Fio.  179. 


441 


Fig.  180. 


The  genu-pectoral  position  ;  showing  its  action  in  retroversion. 

After  replacement  has  been  effected  by  any  one  of  these  methods,  the 
sound  may  be  employed  to  make  sure  of  its  thoroughness  and  to  increase 
it.  It  should  never  be  used  for  this  purpose  before  manual  replacement, 
and  even  after  it  it  should  be  employed  very  cautiously  and  by  the  follow- 
ing steps : — 

1st.  It  should  be  introduced,  but  slightly  bent,  to  the  fundus. 

2d.  Holding  the  handle  in  his  left  hand,  the  operator  should  place  the 
tips  of  the  fingers  of  the  right  hand  upon  the  shaft  and  carry  it  towards 
the  perineum  as  far  as  possible. 

3d.  The  uterus  being  now,  to  a  certain  degree,  straightened  and  ele- 
vated, the  sound  should  be  rotated  so  as  to  throw  the  fundus  forwards,  and 
the  handle  of  the  instrument  held  in  one  hand  be  carried  towards  the 
patient's  back  so  as  to  advance  the  tip  as  far  as  possible  towards  the  ab- 
dominal walls. 

Reading  a  procedure  thus  described  often  leaves  the  impression  that  it 
is  a  complicated  one,  and,  perhaps,  that  the  directions  given  are  unimpor- 


442  POSTERIOR    DISPLACEMENTS    OP    THE    UTERUS. 

tant.  Let  one  who  has  habitually  used  the  sound  simply  as  a  rotator  fairly 
try  this  more  delicate  and  rational  employment  of  it,  and  I  am  sure  that 
he  will  adhere  to  it,  even  although  prejudiced  against  it  originally. 

Sims's  repositor,  likewise,  answers  a  good  purpose  in  rendering  replace- 
ment complete  after  partial  replacement  by  the  fingers. 

Means  for  Retaining  the  litems  in  Position. — Having  replaced  the 
uterus,  the  question  which  arises  is,  How  are  we  to  prevent  the  recurrence 
of  displacement  at  a  very  early  period?  Careful  attention  should  imme- 
diately be  paid  to  the  following  points  :  1,  all  pressure  from  above  should 
be  removed  by  the  use  of  the  skirt  supporter,  the  abdominal  supporter, 
and  avoidance  of  injurious  muscular  efforts  ;  2,  increased  weight  of  the 
uterus  should  be  diminished  by  the  adoption  of  means  already  pointed  out 
for  the  fulfilment  of  this  indication  ;  3,  feebleness  of  the  uterine  supports 
should  be  remedied  by  exercises  calculated  to  develop  the  retentive 
powers  of  the  abdomen  and  by  general  and  local  tonics;  and  4,  all  trac- 
tion upon  the  uterus  should  be  removed  by  perineorrhaphy,  or  this  com- 
bined with  colporrhaphy.  The  fulfilment  of  one  or  of  all  these  indications 
may  at  once  bring  relief  to  a  case  in  which  less  radical  and  more  desul- 
tory efforts  might  be  indefinitely  prolonged  with  only  partial  benefit.  As 
the  means  for  fulfilling  these  indications  have  been  already  fully  pointed 
out,  I  shall  not  repeat  them  here. 

All  causes  which  originally  excited  and  still  perpetuate  the  accident 
having  been  as  far  as  possible  combated,  the  chief  and  most  immediate 
indications  are  clearly  to  replace  the  displaced  uterine  body  and  to  keep 
it  in  position. 

For  the  purpose  of  fully  exhibiting  the  method  of  treating  a  chronic  case 
of  this  disorder,  I  will  suppose  that  we  are  dealing  with  one  of  rebellious 
character,  in  which  there  is  considerable  tenderness  about  the  uterus,  so 
that  it  will  not  tolerate  the  pressure  of  a  pessary  sufficiently  powerful  to  keep 
it  in  position.  The  bowels  should  be  evacuated ;  the  vagina  thoroughly 
syringed  with  warm  water  night  and  morning ;  all  weight  taken  from  the 
abdomen  by  a  skirt  supporter,  an  abdominal  supporter,  and  avoidance  of 
all  muscular  efforts;  and  the  uterus  be  replaced  and  held  in  the  condition 
of  complete  anteversion  for  two  or  three  minutes,  once  in  every  forty-eight 
hours,  for  a  week  or  more.  As  an  additional  preparation  for  the  permanent 
support  of  the  displaced  organ,  a  tampon  of  carbolized  cotton  should  be  ap- 
plied in  the  following  way  :  the  uterus  being  pushed  into  a  state  of  com- 
plete anteversion,  a  roll  of  cotton  about  the  size  of  a  small  hen's  egg,  or  an 
egg-sponge  moistened  with  carbolized  glycerine,  should  be  carefully  pushed 
as  far  as  it  will  go  into  the  fornix  vaginas.  Tlien  a  large  roll  of  cotton 
should  be  placed  below  the  cervix  and  a  little  anterior  to  it  (not  behind  it, 
as  the  first  one  was),  but  so  arranged  as  to  lift  this  part  up  into  the  hollow 
of  the  sacrum  against  the  roll,  which  has  now  become  invisible,  in  the  for- 
nix vaginae.     The  subcervical  tampon  not  only  pushes  back  the  cervix, 


METHODS    OF    RETENTION.  4  to 

which  was  before  its  introduction  near  the  symphysis  pubis,  but  it  still 
further  elevates  the  supra-cervical  roll,  which  thus  pushes  the  fundus 
farther  and  farther  upwards  until  it  topples  over  forwards  by  its  own 
weight,  uninterfered  with  as  it  is  by  pressure  from  above,  and  aided  by 
the  abdominal  decubitus  which  should  be  observed  by  the  patient.  The 
accompanying  diagram  will  explain  the  action  of  these  two  portions  of 

Fig.  181. 


the  tampon  when  properly  applied.  If,  instead  of  being  thus  applied,  the 
ordinary  tampon  be  employed,  and  the  lower  portion  of  the  vagina  be 
tilled,  nothing  is  accomplished  but  elevation  of  the  retroverted  organ. 
What  we  desire  to  produce  is  anteversion.  After  the  introduction  of  the 
cervical  pad  as  shown  in  the  figure,  the  vagina  is  filled  with  cotton  to 
keep  this  in  place,  as  well  as  to  elevate  the  whole  uterus,  and  bring 
gravitation  to  our  aid  in  throwing  the  body  forwards.  I  do  not  look 
upon  the  abdominal  decubitus  as  a  valuable  resource  in  the  treatment  of 
retroversion,  but  merely  as  an  adjuvant  to  other  means,  which  directly 
straighten  the  axis  of  the  uterus.  Lift  the  retroverted  organ,  and  it  has  a 
certain  degree  of  efficacy,  as  an  adjuvant,  which  it  does  not  possess  while 
the  displacement  is  in  existence.  The  tampon  may  be  retained  for  forty- 
eight  hours  without  inconvenience,  if  the  material  of  which  it  is  composed 
be  properly  prepared  by  means  of  antiseptic  drugs. 

Cotton  impregnated  with  antiseptic  and  alterative  substances,  such  as 
borax,  carbolic  and  salicylic  acids,  zinc,  copper,  alum,  iron,  etc.,  may 
now  readily  be  obtained  from  druggists,  so  that  the  physician  need  not 
charge  himself  with  its  preparation. 

During  the  use  of  this  means  the  patient  may  go  about  and  attend  to  her 
usual  avocations,  although  sometimes  it  is  better  to  confine  her  to  bed. 

I  sometimes  effect  the  same  result  by  introducing  a  Hoffman's  or  Hurd's 
inflated  rubber  pessary,  and  then  placing  under  this  a  tampon,  which  will 
press  it  firmly  up  against  the  displaced  fundus. 

Should  the  residence  of  the  patient  be  out  of  the  city,  or  her  pecuniary 


411  POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

condition  render  it  impossible  tor  her  to  be  treated  as  here  advised,  the 
plan   may   be  imitated   by    one  which  is   very 
Fig.  182.  effectual,  and  much  less  troublesome  to  patient 

and  physician.  The  uterus  being  thrown  into 
anteversion  by  the  repositor,  or  two  fingers  in- 
troduced into  the  fornix,  while  the  patient  is  in 
the  left  lateral  position,  a  sponge-pessary,  which 
consists  in  the  attachment  of  a  soft  egg-sponge, 
instead  of  a  bulb,  to  the  stem  of  Cutter's  pes- 

Hoffman'«  inflated,  soft-rubber 

pessary.  sary,  Pig.  191,  should  be  left  in  position.     The 

sponge  fits  in  the  vaginal  cul-de-sac,  is  steadily 
pushed  upwards  against  the  uterus  by  the  elastic  dorsal  strap,  and  forcibly, 
but  gently,  keeps  the  organ  in  normal  position.  For  such  cases  as  those 
just  indicated,  and  for  others  in  which  the  retroversion  is  so  obstinate  that 
it  recurs  in  spite  of  a  pessary  passed  entirely  into  the  vagina,  this  consti- 
tutes a  means  of  such  great  value  that  I  urge  its  trial  in  all  difficult 
cases.  By  it  I  have  controlled  many  cases  which  had  resisted  all  other 
plans  of  mechanical  treatment,  and  feel  assured  that  it  will  not  fail  to  pro- 
duce in  the  hands  of  others  as  good  results  as  it  has  yielded  me.  Of 
course,  it  is  only  a  temporary  and  preparatory  means,  for  sponge  is,  at 
all  times,  an  objectionable  substance  to  leave  in  the  vagina.  It  should,  in 
this  case,  be  removed,  washed,  and  replaced  by  the  patient  once  in  every 
twelve  hours. 

After  the  methods  thus  far  described  have  been  pursued  for  a  month 
or  two,  even  the  worst  cases  will  generally  tolerate  a  well-adjusted  perma- 
nent pessary ;  but  where  this  tolerance  is  not  established,  the  medicated 
tampon,  or  sponge  pessary  should  be  continued  until  it  becomes  so. 

One  important  point  in  connection  with  this  method  of  replacing  the 
uterus  is  this.  The  round  ligaments  are  attached  to  the  horns  of  the 
organ,  and  at  the  vulva.  If  the  retroverted  or  retrotlexed  uterus  be  left 
in  malposition  and  simply  pushed  up,  the  ligaments  will  inevitably  increase 
and  insure  the  continuance  of  the  displacement.  If,  on  the  other  hand, 
the  body  be  thrown  forwards  and  kept  in  anterior  position  until  the  organ 
be  lifted,  the  round  ligaments,  becoming  tense,  tend  to  act  remedially  on 
posterior  deviations.  A  little  thought  will  convince  the  reader  of  the 
truth  of  this  statement.  It  is  upon  this  action  of  the  round  ligaments  that 
I  in  part  depend  for  the  benefit  of  the  plan  which  I  am  describing. 

It  may  be  asked  whether  I  propose  to  treat  all  cases  of  retroversion  in  this 
manner  in  the  beginning.  By  no  means  so.  I  prefaced  these  remarks 
upon  preparatory  treatment  by  stating  that  I  supposed  the  practitioner  to 
be  dealing  with  an  aggravated  case  and  one  intolerant  of  support.  Most; 
cases  will  at  once  admit  of  the  use  of  a  retroversion  pessary,  and  require 
no  preparatory  treatment.  There  are,  however,  many  others  which  do 
require  it  and  in  which  immediate  resort  to  artificial  support  proves  inju- 


PESSARIES.  445 

dieious  and  even  dangerous.  Some  may  suppose  that  a  great  deal  of  time 
must  be  consumed  by  this  preparatory  treatment  which  is  not  absolutely 
necessary  for  the  relief  of  the  case.  If  preparatory  treatment  be  not 
necessary,  it  should  not  be  resorted  to;  if  it  be  necessary,  time  will  be 
gained  and  not  lost  by  its  adoption.  At  least  let  me  urge  this  advice: 
when  the  most  carefully  adjusted  pessaries  create  discomfort,  let  a  month 
be  devoted  to  the  preparatory  treatment  which  I  have  described,  and  at 
its  end  let  pessaries  be  again  tried.  Many  cases  will  then  be  found  to 
yield  to  mechanical  treatment  which  were  rebellious  to  it  before,  and 
more  certainly  so  if  the  means  recommended  for  removing  pressure  upon 
the  fundus  from  above  be  faithfully  put  in  practice.  Some  of  the  most 
gratifying  results  of  gynecology  will  be  found  to  arise  from  a  cautious, 
patient,  and  philosophical  treatment  of  these  cases.  But  let  no  one  sup- 
pose that  a  careless  fulfilment  of  the  directions  given  is  likely  to  perform 
all  this.  If  the  plan  which  I  am  urging  be  used  unintelligently  and 
roughly,  it  will  do  harm  and  not  good,  and  result  in  annoyance  and  not 
comfort  to  the  patient. 

It  has  now  been  decided,  we  will  suppose,  to  try  the  effects  of  a  retro- 
version pessary.  Which  of  the  many  varieties  at  our  command  shall  be 
selected?  The  oldest  and  most  generally  known  of  these  instruments, 
Hodge's  pessary,  still  holds  its  place  in  professional  esteem,  and  is  shown 
in  Fig.  183. 

Fig.  183. 


Hodge's  closed  lever  pessary. 

To  Hodge's  pessary  there  are  two  objections  :  one  is  that  it  lacks  a  point 
of  resistance  at  the  outlet  of  the  pelvis,  which  prevents  it  from  turning 
around;  the  other  is  that  it  does  not  carry  the  body  of  the  uterus  high 
enough  up  in  some  cases.  These  defects  Dr.  Albert  Smith  has  well  met 
in  the  modification  of  Hodge's  instrument  which  is  shown  in  Fig.  184. 

I  likewise  very  commonly  employ,  in  cases  in  which  I  desire  to  carry 
the  retroflexed  fundus  very  high  in  the  pelvis,  the  instrument  shown  in 
Fig.  185. 

It  is  a  long  and  narrow  instrument,  surmounted  at  its  upper  extremity 
by  a  bulb,  and  measures  between  its  branches  at  the  widest  part  seven- 
eighths  of  an  inch  in  the  smallest  sizes,  and  one  and  one-eighth  of  an  inch 


446 


POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


in  the  largest ;  upon  its  upper  extremity  is  a  bulb  which  prevents  cutting 
of  the  tissues;  its  lower  extremity  rests  against  the  tissues  under  the 
pubes ;  and  it  is  five  inches  long  in  the  largest  sizes,  and  four  and  a  quar- 


Fig.  184. 


T,£MA"N 


Albert  Smith's  pessary. 

ter  in  the  smallest,  measured  along  the  outside  curve  of  the  branches. 
Spanning  the  pelvis,  this  narrow  instrument  stretches  the  vagina  without 
distending  it,  and  pushes  the  fundus  to  a  higher  point  than  any  other 
with  which  I  am  familiar.  Its  retention  depends  not  upon  its  size  but 
its  relation  to  the  pelvis,  for  it  is  prevented  from  escaping  not  by  separa- 
tion of  its  branches,  but  by  the  length  and  degree  of  the  post-uterine 
curve,  and  by  the  retention  established  by  the  tissues  under  the  pubes 
against  the  downward  curved  lower  extremity. 

Fig.  185. 


Thomas's  retroflexion  pessary. 

The  same  instrument  is  also  very  cleverly  made  by  Mr.  Otto,  of  this 
city,  of  elastic  spiral  wire,  covered  with  soft  rubber,  and  ending  in  a  soft 
rubber  cushion  or  bulb  at  its  upper  extremity,  as  showm  in  Fig.  186. 

To  a  limited  degree  support  may  in  these  cases  be  obtained  by  the 
elastic  ring  pessary  of  Meigs,  which  has  been  as  variously  altered  as  the 
lever  of  Hodge,  but  this  instrument  in  posterior  and  anterior  displacements 
is  only  palliative  and  imperfect  in  mechanism. 


PESSARIES. 


447 


Nevertheless  this  instrument,  imperfect  as  it  is,  cannot  he  discarded  \>y 
the  gynecologist,  for  in  some  cases  it  answers  a  purpose  which  no  other 


Fig.  180. 


Elastic  bulb  pessary. 


Fig.  187. 


instrument  can  be  made  to  do.  To  one 
unaccustomed  to  the  use  of  pessaries  the 
simplicity  and  elasticity  of  this  instru- 
ment will  prove  very  seductive,  and  lead 
to  a  belief  in  its  perfect  harmlessness. 
Such  a  reliance  will  prove  utterly  delu- 
sive. Even  the  most  elastic  instrument 
will  often  cut  through  the  vaginal  walls 
when  it  is  a  little  too  large.  It  is  indeed 
more  liable  to  produce  this  result  than 
any  other  variety  of  pessary. 

Sometimes  the  posterior  uterine  wall 
becomes    the    site    of  a    fibrous    tumor, 
which,  by  keeping  up  congestion  by  its  presence  as  well  as  by  the  flexion 
which  it  induces  or  aggravates,  renders  the  whole  fundus   so  tender,  that 


Meigs's  elastic  ring  pessary. 


Fig.  188. 


Fig.  189. 


Hurd's  pessary. 


Retro-flexed  uterus  in  Hurd's  pessary. 


an  ordinary  pessary  cannot  be  tolerated.     In  such  cases  the  bulb  should  be 
removed  from  the  modified  Cutter's  pessary  and  replaced  by  a  soft  sponge, 


448  POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 

and  by  this  the  uterus  may  be  supported.  Under  these  circumstances 
Hurd's  pessary,  Fig.  188,  will  be  found  to  answer  a  good  purpose,  and  the 
inflated,  soft  rubber  pessary  of  Hoffman,  Fig.  182,  is  also  a  serviceable 
temporary  resort,  alone  or  combined  with  the  tampon,  which  greatly  in- 
creases their  efficiency.  Where  tenderness  is  excessive,  it  will  often  be 
found  to  be  a  wiser  course  to  pack  the  fornix  with  medicated  cotton  or 
sponge,  and  elevate  the  whole  uterus,  as  already  advised.  By  employing 
this  method  for  a  time,  a  pessary  will  soon  be  tolerated. 

These  are  the  instruments  which  I  employ  in  ordinary  cases  of  posterior 
displacement  of  the  uterus.     There  are  other  varieties,  however,  which 

often  answer  an  excellent  purpose. 
Fig.  190.  Hewitt's  pessary  is  an  excellent  one, 

if  the  weight  to  be  sustained  be 
slight.  If  it  be  at  all  great,  this 
instrument  is  utterly  inadequate  to 
cope  with  it.  It  is  not  simply  in- 
efficient ;  it  is  in  such  cases  a 
dangerous  instrument,  for  resting 
against  the  soft  parts  covering  the 
symphysis  pubis  it  may,  as  I  have 
„     ..,,  seen  it  do,  cut  directly  through. 

Hewitt  s  pessary.  J  ° 

In  a  certain  number  of  cases  the 
displaced  uterine  body  is  so  heavy  and  presses  so  forcibly  downwards  that 
a  pessary  of  ordinary  size  is  driven  out  of  the  vagina,  or  so  low  down  as 
to  allow  descent  of  the  fundus.  This  might  be  obviated  by  employing  an 
instrument  of  large  size  and  great  expansion  of  limbs,  but  this  the  vagina 
cannot  tolerate.  It  sets  up  ulceration  and  creates  pain  from  pressure  and 
distension.  In  other  words  ;  without  a  very  firm  base  the  uterus  forces 
out  the  instrument ;  with  a  sufficiently  firm  base  to  resist  this,  ulceration 
from  excessive  pressure  results.  In  some  cases  indeed,  so  very  great  is 
the  pressure  exerted  by  the  displaced  uterus,  that  no  purely  internal  sup- 
port will  answer  the  purpose  of  sustaining  it,  for  the  point  against  which 
either  the  pubic  or  uterine  extremity  of  the  instrument  rests  will,  in  spite 
of  every  precaution,  become  ulcerated.  Under  these  circumstances  I  have 
obtained  the  most  gratifying  results  from  the  use  of  a  modification  of 
Cutter's  retroversion  pessary,  intended  to  obviate  a  difficulty  which  I 
found  attended  that  excellent  instrument,  that  of  cutting  through  the 
vagina.  If  no  great  amount  of  pressure  is  to  be  borne,  Cutter's  pessary 
answers  very  well  for  this  purpose  ;  if  great  pressure  is  to  be  borne,  the 
point  of  his  instrument  endangers  the  tissues.  For  this  reason  I  have 
affixed  to  the  top  of  Cutter's  pessary  bulbs  of  different  sizes — some  as  large 
as  a  hickory  nut — for  the  object  is  not  only  to  prevent  cutting  of  the  vagina, 
but  to  place  behind  the  displaced  fundus  a  mass  which  will  make  it  fall 
forwards  by  displacement,  and  not  by  pressure.     My  alteration  of  this  in- 


PESSARIES.  449 

strument  is  insignificant ;  the  entire  credit  of  it  belongs  to  Dr.  Cutter,  to 
whom  the  profession  is  indebted  for  affording  it  so  valuable  and  simple  a 
method  for  meeting  the  difficulties  of  aggravated  retroversion.  Had  I 
space,  I  could   cite  a   number  of  very  bad  cases  of  this  difficulty,  which 

Fig.  191.  Fig.  192. 


Cutter's  pessary.  Thomas's  modification  of  Cutter's  pessary. 

had  for  years  resisted  treatment  by  ordinary  pessaries,  and  which  have 
readily  yielded  to  the  use  of  Cutter's  instrument,  or  this  modification  of 
it.  The  inferior  extremity  of  this  pessary  arches  backwards  over  the 
coccyx,  and  attaches  to  an  elastic  cord  which  passes  upwards  over  the 
sacrum  to  a  girdle  around  the  waist.  It  is  a  painless  and  efficient  method 
of  giving  support,  and  will  gain  a  high  reputation  on  account  of  these 
qualities  in  posterior  displacements.  The  class  of  cases  to  which  it  is 
especially  applicable,  is  that  in  which  the  displacement  is  due  to  prolapse 
of  the  posterior  vaginal  wall  from  rupture  of  the  perineum  or  other  cause. 
When  employed  for  posterior  displacements,  the  upper  extremity  of  the 
instrument  simply  lies  in  the  fornix  vagina?,  the  cervix  of  course  not  en- 
tering the  fenestra. 

This  instrument  should  be  removed  every  night  and  reinserted  every 
morning.  It  may  be  said  that  this  will  prove  difficult  of  accomplishment 
for  the  patient.  Out  of  several  hundred  cases  in  which  I  have  used  it,  I 
have  never  found  an  instance  of  failure  in  this  respect.  The  patient  will 
very  often  become  disaffected  towards  the  instrument  from  its  chafing  the 
perineum.  By  a  little  patience,  covering  the  points  which  rub  with  greased 
lint,  and  leaving  the  pessary  out  until  the  irritated  part  be  healed,  the 
feeling  will  soon  pass  away. 

It  will  be  observed,  that  thus  far  we  have  dealt,  in  treating  of  the  me- 
chanical means  for  sustaining  the  flexed  uterine  body,  with  those  which 
directly  push  the  fundus  upwards,  in  the  hope  that  in  time  it  will  fall  for- 
wards of  its  own  weight  and  assume  a  natural  position.  In  some  cases 
this  is  not  enough ;  we  are  forced  to  do  that  at  the  same  time  that  we 
elevate  as  far  as  possible  the  cervix  into  the  hollow  of  the  sacrum,  and  thus 
increase  the  liability  of  the  uterine  body  to  fall  forwards.  In  other  words, 
29 


450 


POSTERIOR    DISPLACEMENTS    OF    THE    UTERUS. 


Fig.  193. 


there  are  two  forces  which  may,  through  a  pessary,  overcome  retroflexion : 
first,  that  which  pushes  the  corpus  uteri  upwards  and  forwards  ;  second, 

that  which  pushes  the  cervix  up- 
wards and  backwards.  The  first  of 
these  often  proves  quite  sufficient 
without  the  second,  but  sometimes 
the  direct  and  steady  pressure  upon 
the  uterine  body  involved  in  it  be- 
comes intolerable.  Then  is  it  that 
the  second,  which  alone  is  never  suffi- 
cient, comes  into  play  as  an  efficient 
adjuvant.  I  have  often  seen  the  prac- 
tice of  the  double  method  effect  cures 
which  seemed  to  have  been  impos- 
sible by  that  of  a  single  one.  I  deem 
this  point  of  sufficient  importance 
to  illustrate  it  by  schematic  dia- 
grams. . 

This  double  action  is  developed  by 

the   post-cervical  and  ante-cervical 

tampon,  by  the  sponge  and  tampon, 

Forco  applied  to  uterine  body  aioue.  and  by  Hurd's  pessary  and  a  tam- 


Fig.  194. 


Force  simnltancously  applied  to  cervix  and  body. 

pon.     I  now  show  two  pessaries  which  accomplish  the  same  end,  one  an 
addition  to  the  Hodge  pessary,  the  other  a  modification  of  the  Cutter. 


PESSARIES, 


451 


The  second  is  so  uncouth  in  appearance  that  one  instinctively  feels  preju- 
diced against  it,  but  I  would  ask  for  it  a  fair  trial,  and  assure  my  readers 
that  it  has  proved,  in  my  hands,  a  most  valuable  resource  in  a  class  of 
cases  of  most  intractable  character. 


Fig.  195. 


Fig.  196. 


Retroflexion  pessary  with  cervical  rest. 


Modification  of  Cutter's  pessary 
with  cervical  rest. 


It  will  be  at  once  appreciated  that  the  anterior  arm  in  each  of  these 
instruments  lifts  the  cervix  upwards,  as  the  anterior  ball  does  in  Fig.  194. 

By  these  means  a  uterus  affected  by  a  reducible  retroflexion  may,  in  all 
conditions  excepting  the  unfavorable  ones  already  mentioned,  be  restored 
to  its  place  and  kept  there  without  resort  to  the  intra-uterine  stem  or  a 
cutting  operation.     These  unfavorable  conditions  we  will  now  consider. 

When  the  vagina  unites  itself  to  the  cervix  so  near  its  lowest  point  as 
to  leave  almost  no  post-cervical  space,  it  is  impossible  to  sustain  the  uterus 
by  any  vaginal  pessary.  Under  these  circumstances,  and  these  alone,  I 
believe  the  intra-uterine  stem  to  be  necessary  in  posterior  displacement. 
Those  which  were  recommended  in  anteflexion  will  answer  here. 

Anteflexion  is  probably  often  a  congenital  condition,  or  continues  for  so 
long  a  period  during  the  life  of  the  girl  before  it  is  discovered,  that  the 
anterior  inflexion  becomes  an  irreducible  uterine  deformity.  This  is  some- 
times, though  much  less  frequently,  so  in  retroflexion,  which  is  usually 
reducible,  unless  the  flexed  body  be  bound  down  by  false  membranes,  the 
result  of  slight  peritonitis.  It  is  sometimes  difficult  in  a  given  case  to 
decide  the  cause  of  the  permanency  of  the  displacement.  In  a  general 
way  it  may  be  said,  that,  if  it  be  due  to  false  membranous  attachment,  the 
uterus  will  not  move  from  its  position  in  the  pelvis  ;  if  it  be  due  to  con- 
traction in  the  tissue  of  the  uterus  itself,  the  organ  will  change  its  pelvic 
relations,  but  not  the  abnormal  ones  existing  between  body  and  neck. 

In  case  the  flexion  be  found  due  to  parenchymatous  alteration,  no  sur- 


452 


POSTERIOR  DISPLACEMENTS  OF  THE  UTERUS. 


gical  procedure  should  be  adopted  ;  but  the  body  should  be  cautiously  bent 
forwards  once  or  twice  a  week  by  means  of  the  sound  or  repositor,  and 
kept  in  anterior  inclination  by  means  of  the  retroflexion  pessary  shown  in 
Fig.  195,  or  by  the  modified  Cutter's  pessary. 

If  the  uterus  be  found  fixed  in  the  position  of  retroflexion  by  false  mem- 
branous attachments  not  of  recent  origin,  and  the  patient  be  not  suffering 
to  such  an  extent  from  the  displacement  as  to  render  reposition  urgently 
necessary,  it  had  better  be  left  undisturbed  in  its  unnatural  place.  Should 
the  disorder,  however,  be  affecting  the  health,  or  causing  such  pain  and 
discomfort  as  to  render  the  incurring  of  the  risk  of  peritonitis  warrantable, 
reduction  should  be  accomplished  in  this  way.  The  patient  having  been 
anaesthetized  and  placed  in  the  left  lateral  position,  the  sphincter  ani 
should  be  stretched  by  the  thumbs.  Then  the  index  and  middle  fingers 
of  the  right  hand  should  be  passed,  with  the  palmar  surfaces  towards  the 
sacrum,  up  the  rectum  to  the  flexed  uterine  body.  Steady  pressure  should 
then  be  made  upon  it  until  the  organ  is  lifted  upright,  when,  the  fingers 
being  made  to  describe  the  arc  of  a  circle  towards  the  pubes,  the  outer 
surfaces  of  the  finger-nails  will  be  in  contact  with  the  uterine  body,  and 
by  them  it  will  be  pushed  over  into  an  anterior  position.  After  this  the 
fornix  should  be  filled  with  a  soft,  moist  sponge,  and  this  be  forced  up  so 
as  to  sustain  the  body  by  a  tampon  of  cotton  in  the  vagina.  After  this 
the  patient  should  be  kept  very  quiet  for  a  week,  and  all  pain  should  be 
soothed  by  free  use  of  opium,  as  a  preventive  of  peritonitis. 


Fig.  197. 


Latero  flexion. 

Sometimes  the  uterus  is  flexed  to  the  right  or  left  side  as  a  consequence  of 
disease  of  its  proper  tissue  or  of  direct  pressure.  This  variety  of  displace- 
ment rarely  attains  to  such  a  degree, 
however,  as  to  result  in  obstruction  of 
the  uterine  canal.  Its  chief  import- 
ance is  connected  with  diagnosis,  for  it 
may  readily  be  mistaken  for,  periute- 
rine inflammation  or  a  fibrous  tumor. 
The  practice  of  conjoined  manipulation 
and  the  use  of  the  uterine  probe  will 
always  settle  the  point. 

The  treatment  of  lateroflexion  should 
be  conducted  u[>on  precisely  the  same 
principles  which  guide  us  in  reference 
to  anteflexion  and  retroflexion.  Of  all 
varieties  of  flexion  this  is  the  most 
likely  to  require  the  use  of  the  intra- 
uterine stem,  for  it  is  exceedingly  difficult,  I  may  even  say  rarely  possi- 
ble, to  overcome  it  by  a  vaginal  instrument.   "When  this  necessity  presents 


INVERSION    OF    THE    UTERUS. 


453 


itself,  either  in  retroflexion  or  lateroflexion,  I  employ  the  intra-uterine 
stem  represented  in  Fig.  197.  The  fundus  is  in  part  sustained  by  tin- 
pessary,  not  entirely  by  the  stem. 

After  the  introduction  of  every  pessary,  the  position  of  the  uterine  body 
should  be  at  once  examined,  either  by  the  probe,  by  conjoined  manipula- 
tion, or  by  both,  to  ascertain  whether  the  instrument  be  efficient  or  not. 
If  it  be  not  so,  it  is  imperfect,  for  the  object  is  not  to  go  through  the  form 
of  introducing  a  pessary ;  it  is  to  rectify  the  malposition  of  the  uterus. 
At  the  next  and  at  every  subsequent  visit  of  the  patient,  this  examination 
should  be  made  before  removal  of  the  instrument,  in  order  to  test  the  effect 
of  time  and  movement  upon  the  position  of  the  supported  uterus. 


CHAPTER  XXIX. 


INVERSION  OF  THE  UTERUS. 


Definition This  dangerous  and  infrequent  form  of  displacement  con- 
sists in  the  turning  of  the  uterus  inside  out.  As  the  bottom  of  a  bag  may 
be  pushed  through  its  mouth,  so  that  the  inner  surface  becomes  the  outer, 
so  may  that  of  the  uterus,  and  the  occurrence  of  such  an  accident  consti- 
tutes the  disease  which  we  are  considering. 

Varieties Writers  differ  in   classifying  the  varieties  of  the  affection, 

some  describing  three  and  some  four  forms.     For  practical  purposes  all 


Fig.  198. 


Fig.  199. 


Partial  inversion. 


Complete  inversion. 


these  may  be  brought  under  two  heads — partial  and  complete.  In  the 
first  the  body  has  become  depressed,  but  has  not  passed  through  the  os. 
In  the  second  the  uterus  has  been  turned  completely  inside  out,  and  the 
inverted   fundus  and   body   hang  in   the  vagina  or  between   the  thighs, 


454  INVERSION  OP  THE  UTERUS. 

"velut  scrotum,"  as  it  has  been   expressed  by  Hippocrates.     Fig.  198 
represents  the  first,  and  Fig.  199  the  second  form  of  tbe  accident. 

In  addition  to  these  varieties  the  accident  must  be  divided  into  acute 
and  chronic,  or  sudden  and  gradual  inversion,  as  it  occurs  rapidly  or 
slowly. 

Anatomy — In  treating  of  flexions  of  the  uterus,  it  was  remarked  that 
they  are  chiefly  prevented  by  the  resisting  nature  of  the  parenchyma  of 
the  cervix  which  supports  the  fundus  and  body.  A  similar  function  on 
the  part  of  the  entire  uterine  structure  keeps  the  cavities  of  the  neck  and 
body  closed,  and  prevents  inversion.  Should  that  power,  which  in  the 
pregnant  uterus  we  call  contractility,  and  in  the  non-pregnant,  tone,  be  to 
any  great  degree  impaired,  the  body  of  the  organ,  bereft  of  support,  will 
incline  forwards  or  backwards.  Should  it  be  entirely  abolished,  the  fundus 
under  the  influence  of  traction  or  downward  pressure  may  pass  through 
the  unresisting  os  and  escape  into  the  vagina,  constituting  inversion.  I 
once  saw  this  perfectly  illustrated  in  a  cadaver  upon  which  I  was  called 
to  perform  version  soon  after  death.  As  I  extracted  the  child  the  flaccid 
uterus  followed  it  directly  and  was  completely  inverted,  the  placenta 
still  adhering. 

Pathology The  accident  depends  for  its  production  upon  two  ele- 
ments— 

1st.  Relaxation  and  inertia  of  the  uterine  walls; 
2d.  Downward  traction  or  pressure. 

The  first  of  these  may  be  a  primary  and  original  state,  or  it  may  be 
induced  by  the  second  after  months  of  exhausting  action.  For  example, 
after  labor  the  uterine  walls  may  remain  lax  and  atonic  from  inherent 
inertia;  or  their  tissue  in  the  non-pregnant  state  may  be  firm  and  resist- 
ing, yet  in  time  be  overcome  by  the  traction  and  dilatation  exerted  by  a 
large  fibrous  polypus  attached  to  the  fundus. 

In  the  limited  space  which  I  can  allot  to  this  subject  it  is  impossible  to 
present  the  various  theories  which  have  been  advanced  for  the  explanation 
of  the  mechanism  of  inversion  ;  nor  would  it  be  beneficial  for  the  student 
that  I  should  do  so.  In  place  of  such  an  effort  I  shall  mention  those 
which  appear  to  me  to  possess  a  really  important  and  practical  bearing 
upon  the  subject. 

The  three  views  to  which  I  shall  direct  attention  are  the  following: — 

1st.  That  some  part  of  the  relaxed  body  prolapses,  and  passing  out  of 
the  cervix  drags  the  entire  uterine  body  with  it. 

2d.  That  some  part  of  the  relaxed  body  prolapsing,  acts  as  an  excitant 
of  uterine  contraction  which  forces  the  remaining  portion  through  the  cer- 
vix, and  thus  inverts  the  whole  organ. 

3d.  That  lateral  traction  and  direct  pressure  on  a  cervix  the  tissue  of 
which  is  abnormally  soft,  causes  eversion  of  this  part  and  gradually  of  the 
whole  uterus. 


PATHOLOGY.  455 

The  first  of  these  is  the  oldest  and  even  at  present  the  most  generally 
received  view  as  to  the  mechanism  of  inversion.  According  to  it,  it  was 
generally  supposed  that  the  part  of  the  fundus  which  iirst  undergoes  in- 
version is  the  middle.  This  is  denied  by  Oldham  and  Kiwisch,  who 
maintain  that  one  horn  first  inverts  itself  and  is  followed  by  the  fundus, 
the  other  horn,  and  then  the  entire  body.  I  have  met  with  one  case  which 
proves  incontestably  that,  even  if  this  be  not  a  rule,  inversion  at  least 
occurs  in  this  manner  sometimes.  A  patient  who  for  several  years  had 
suffered  from  menorrhagia  applied  to  Prof.  C.  A.  Budd,  of  this  city,  for 
treatment.  Upon  examination  he  discovered  what  he  supposed  to  be  a 
fibrous  polypus  equal  in  size  to  a  hen's  egg  attached  to  the  uterine  cavity 
near  the  entrance  of  the  right  Fallopian  tube.  Carefully  differentiating 
this,  as  he  supposed,  from  partial  inversion,  he  applied  the  ecraseur  and 
removed  it,  when  he  discovered  that  he  had  removed  one  horn  of  the  ute- 
rus with  a  part  of  the  corresponding  Fallopian  tube  and  round  ligament. 
The  case,  which  was  one  of  partial  inversion,  was  not  susceptible  of  diag- 
nosis. The  menorrhagia  attending  it  was  entirely  relieved  by  the  opera- 
tion, the  patient  rapidly  recovering. 

When  the  accident  begins  in  this  way,  the  inverted  horn  pulls  down 
the  other  parts,  with  greater  or  less  rapidity,  and  thus  the  method  of  occur- 
rence may  be  lost  sight  of.  Rokitansky,  in  speaking  of  irregular  post- 
partum uterine  contraction^,  thus  describes  partial  inversion,  with  which 
he  has  twice  met :  "We  must  here  mention  a  very  singular  circumstance 
which  may,  on  account  of  the  consequent  danger,  become  important,  and 
may  even  be  misunderstood  in  post-mortem  examinations ;  it  is  paralysis 
of  the  placental  portion  of  the  uterus  occurring  at  the  same  time  that  the 
surrounding  parts  go  through  the  ordinary  processes  of  reduction.  It 
induces  a  very  peculiar  appearance.  The  part  which  gave  attachment  to 
the  placenta  is  forced  into  the  cavity  of  the  uterus  by  the  contraction  of 
the  surrounding  tissue,  so  as  to  project  in  the  shape  of  a  conical  tumor, 
and  a  slight  indentation  is  noticed  at  the  corresponding  point  of  the  exter- 
nal uterine  surface.  The  close  resemblance  of  the  paralyzed  segment  of 
the  uterus  to  a  fibrous  polypus  may  easily  induce  a  mistake  in  the  diagno- 
sis, and  nothing  but  a  minute  examination  of  the  tissue  can  solve  the 
question.  The  affection  always  causes  hemorrhage,  which  lasts  for  several 
weeks  after  childbirth,  and  proves  fatal  by  the  consequent  exhaustion." 

Since  the  days  of  Astruc,  the  theory  has  been  at  various  times  main- 
tained that  active  contraction  of  the  uterus  sometimes  produces  inversion. 
"  Sometimes,"  says  Astruc,  "it  is  produced  from  contraction  of  the  womb, 
which  forces  the  bottom  inside  out,  through  the  mouth  of  the  womb,  which 
is  not  yet  closed."  Regular  uterine  contraction,  however  violent  it  may 
be,  would  only  tend  to  complete  closure  of  the  uterine  cavity.  If,  how- 
ever, such  a  partial  inversion  or  internal  projection  as  that  alluded  to  by 
Rokitansky,  in  the  quotation  recently  made,  occur,  it  acts  as  the  placenta, 


456  INVERSION    OF    THE    UTERUS. 

the  hand  of  the  obstetrician,  or  any  other  body  in  the  cavity,  by  exciting 
expulsive  efforts  which  may  succeed  in  driving  it  out  of  the  os  externum. 
Should  they  do  so,  complete  inversion  is  the  result ;  should  they  fail,  the 
projection  may  persist  as  a  partial  inversion.  This  view,  which  was  advo- 
cated by  the  late  Dr.  Tyler  Smith,  appears  to  me  to  explain  the  apparent 
paradox  of  inversion  with  tonic  contractions  of  the  uterus  more  satisfac- 
torily than  any  other  which  has  been  advanced.  I  have  met  with  one 
case  occurring  after  delivery,  which  convinces  me,  that  sometimes,  at 
least,  what  I  have  just  described  really  takes  place. 

Still  another  and  very  ingenious  theory  has  been  advanced  by  Prof.  I. 
E.  Taylor  for  explaining  the  occurrence  of  inversion.  It  is  that  inversion 
sometimes  begins  at  the  cervix,  this  part  undergoing  eversion  as  in  pro- 
lapsus, and  this  going  on  to  the  complete  inversion  of  the  entire  organ. 

In  previous  literature,  allusions  to  the  possibility  of  inversion  after  this 
method  may  be  found.  Klob  alludes  to  it  in  these  words:  "A  very  re- 
markable class  of  cases  of  inversion  are  those  in  which,  without  efficient 
cause,  an  inversion  of  the  cervix  into  the  vagina  takes  place,  drawing  the 
fornix  of  the  latter  with  it,  and  thus  forming  a  polypus-like  tumor  in  the 
cavity  of  the  vagina,  which  may  reach  down  to  the  vulva,  at  the  lower 
part  of  which  the  internal  orifice  is  situated."  A  very  striking  case  was 
published  by  Mr.  William  Lawrence  in  the  London  Medical  Gazette, 
Dec.  5,  1838,  under  the  head  of  "  Spontaneous  Partial  Inversion  of  the 
Uterus."  But  the  credit  of  having  drawn  proper  attention  to  the  subject 
and  having  proclaimed  its  probable  pathological  bearings,  unquestionably 
belongs  to  Taylor.  I  say  "  probable,"  for  the  reason  that  it  is  not  yet 
proved.  I  accept  it,  because  my  own  observation  leads  me  to  believe  that 
Dr.  Taylor's  deductions  are  probably  correct. 

Predisposing  Causes. — Every  influence  which  destroys  the  tone  and 
resistance  of  the  uterine  parenchyma  proves  a  predisposing  cause  of  this 
condition.     As  examples,  may  be  mentioned — 

Parturition  ; 

Distention  of  uterus  by  retained  fluids ; 

Distention  of  uterus  by  tumors  ; 

Spongy  softening  of  tissue  in  prolapsus  (?). 

Exciting  Causes A  uterus  in  which  the  tone  of  the  walls  has  been 

destroyed  by  physiological,  pathological,  or  mechanical  causes  has  lost  all 
its  normal  safeguards  against  inversion.  Thus,  we  may  say,  that  any- 
thing which  produces  distention  and  relaxation  of  the  tissue  of  the  uterus 
prepares  the  way  for  inversion  so  completely  that  a  very  trifling  exciting 
cause  may  produce  it.  For  example,  any  decided  traction  or  pressure 
exerted  upon  the  fundus  of  a  uterus  thus  affected,  even  to  a  limited  de- 
gree, may  directly  result  in  it.     The  exciting  causes  are  thus  presented: — 


EXCITING    CAUSES.  457 

Traction  on  placenta  ; 
Traction  by  polypi  or  tumors ; 
Sudden  delivery  of  child  by  traction  ; 
Muscular  efforts  when  relaxation  exists ; 
Prolapsus  uteri  (?). 

Instances  of  its  production  by  all  these  causes  are  on  record,  though  by 
far  the  greatest  number  of  cases  has  followed  parturition.  Of  400  cases 
collected  by  Dr.  Crosse,  of  Norwich,  England,  3i)0  followed  delivery,  and 
of  the  remaining  50,  forty  were  due  to  polypi.  This  disproportionate 
frequency  does  not,  however,  invalidate  the  fact  that  the  other  causes 
mentioned  have  resulted  and  may  result  in  the  accident.  Most  frequently 
it  occurs  very  soon  after  delivery,  though  Ane  and  Baudelocque  report 
its  having  taken  place  on  the  third,  and  Leblanc  on  the  tenth  day. 

Traction  and  relaxation,  when  combined,  are  evidently  sufficient  for 
the  induction  of  the  accident,  and  it  is  generally  to  a  union  of  the  two 
that  it  is  due.  The  question  now  arises  whether  either  of  them  alone 
can  cause  it.  With  reference  to  the  efficiency  of  the  second  element,  the 
answer  may  be  affirmative,  since,  with  complete  relaxation,  inversion  may 
occur  from  a  very  insignificant  exciting  cause,  as  coughing,  sneezing,  or 
a  change  of  posture.  As  to  the  possibility  of  any  amount  of  force  inverting 
the  non-pregnant  and  undilated  uterus,  much  doubt  has  been  expressed. 
At  first  thought,  every  one  will  feel  inclined  to  express  a  decidedly  nega- 
tive opinion,  but  the  evidence  on  record  in  favor  of  such  a  possibility  is 
too  strong  to  be  entirely  ignored.  A  portion  of  it  is  therefore  laid  before 
the  reader. 

Puzos,1  in  1744,  read  before  the  Academy  of  Medicine  of  Paris  a 
memoir  in  which  he  declared  that  he  had  seen  the  accident  in  women  who 
had  never  borne  children.  Boyer2  cites  a  similar  example  in  a  female 
whose  uterus  contained  no  foreign  body,  and  Daillez3  tells  us  that  Baudo- 
locque  met  with  a  case  in  a  girl  fifteen  years  of  age,  in  whom  clandestine 
delivery  could  not  have  occurred,  since  a  perfect  hymen  existed. 

Prof.  Willard  Parker,  of  New  York,  furnishes  me  with  the  history  of 
the  following  case.  A  young  woman  who  had  borne  one  child,  seven  or 
eight  years  previously,  and  had  never  had  any  recognized  uterine  disease, 
while  making  a  violent  effort  in  rolling  tenpins,  suddenly  felt  something 
give  way  within  her,  after  which  she  suffered  the  most  intense  pain  and 
became  completely  disabled.  Dr.  Parker  being  called  to  see  her,  after  a 
hasty  examination  coincided  with  the  opinion  of  the  attending  physician, 
that  a  polypus  had  been  suddenly  expelled  and  was  hanging  in  the  vagina. 
Impressed  with  this  belief  he  removed  the  whole  mass,  when,  to  his  sur- 
prise, he  found  that  he  held  in  his  hands  the  inverted  uterus  with  its  tubes 

1  Colombat  on  Females.     Meigs,  p.  182. 

2  Traitfi  des  Mai.  Cliirurgicales.  3  Colombat,  op.  cit. 


458  INVERSION  OF  THE  UTERUS. 

and  ligaments.     The  patient  recovered  without  any  bad  symptoms,  and 
subsequently  menstruated  regularly. 

Menstruation,  after  amputation  of  the  uterus,  is  by  no  means  rare.  It 
must  be  remembered  that  in  such  an  operation  the  whole  uterus  is  not 
removed.     It  is  from  the  remaining  stump  that  the  flow  occurs. 

It  is  certainly  difficult  to  admit  the  occurrence  of  inversion  beginning 
in  the  body  of  an  undilated  uterus.  It  may  be  that  in  these  cases  some 
distending  influence  which  escaped  observation  preceded  the  accident. 
The  suggestion  of  Colombat  is  certainly  very  plausible,  that  hydrometra, 
physometra,  or  retention  of  the  menses  must,  in  such  cases,  have  pro- 
duced dilatation,  which,  being  followed  by  pressure  just  after  the  escape 
of  the  contained  air  or  fluid,  gave  rise  to  the  displacement.  It  may  be 
that  inversion  begins  in  such  cases  at  the  cervix  and  becomes  complete  in 
the  method  suggested  by  Taylor. 

After  all,  there  is  nothing  more  astounding  in  the  fact  of  spontaneous 
inversion  of  an  undistended  uterus  than  there  is  in  the  spontaneous  repo- 
sition of  one  which  has  been  long  inverted,  and  this  we  have,  with  the 
positive  testimony  of  scientific  and  reliable  men  now  on  record,  no  possible 
justification  for  doubting.  Of  late  the  validity  of  both  these  phenomena 
has  been  denied.  There  is  nothing  easier  than  the  rejection  of  the  testi- 
mony of  others,  and  the  discrediting  of  deductions  which  we  ourselves 
have  not  drawn.  When  De  La  Barre  presented  his  case  of  spontaneous 
reposition  to  the  Academy  of  Surgery,  Baudelocque  was  appointed  a  com- 
mittee to  examine  into  it,  and  reported  that  it  was  "  totally  false."  Some 
years  afterwards  he  met  with  a  very  similar  case,  and  yielded  to  the  evi- 
dence of  his  own,  senses  a  credence  which  he  had  presumptuously  denied 
to  the  assertions  of  another. 

Symptoms. — Should  inversion  occur  suddenly,  as  for  instance  after  de- 
liver}', the  patient  will  complain  of  discomfort  about  the  vulva,  faintness 
and  nervous  disturbance.  Hemorrhage  and  tendency  to  collapse  will  show 
themselves,  and  unless  proper  treatment  be  adopted  at  an  early  period, 
death  may  ensue.  A  physical  examination  will  at  once  settle  the  diagno- 
sis, for  a  large,  flabby,  globular  mass,  perhaps  with  the  placenta  attached 
to  it,  will  be  found  between  the  thighs  of  the  patient  if  inversion  be  com- 
plete. But  very  often  no  diagnosis  will  have  been  made  at  the  time  of  its 
occurrence,  and  months,  perhaps  years,  afterwards,  the  physician  will  be 
called  upon  to  determine  the  character  of  the  case,  which  will  probably 
present  the  following  symptoms  : — 

Occasional  or  constant  hemorrhage  ; 

Dragging  pains  in  back  and  loins  ; 

Difficulty  in  locomotion ; 

Difficulty  in  defecation  and  micturition  ; 

Anamiia  and  its  accompanying  evils. 


PHYSICAL    SIGNS. 


459 


Physical  Signs — All  these  symptoms  belong  as  much  to  polypus,  fibrous 
tumor,  and  cancer,  as  to  inversion,  and  to  determine  their  true  cause, 
physical  exploration  is  indispensable.  Should  the  inversion  be  complete, 
the  finger  being  introduced  into  the  vagina  will  meet  with  a  tumor  which 
the  examiner  will  at  once  know  is  either  the  displaced  body  of  the  uterus 
or  a  polypus,  and  his  attention  will  be  directed  to  their  differentiation. 


IF  IT  BE  A  POLYPUS. 

The  probe  will  usually  pass  by  its  side 
into  tins  uterus  ; 

Conjoined  manipulation  will  reveal 
the  uterine  body. 

Rectal  examination  will  reveal  the 
uterus  in  sitti; 

Recto-vesical  exploration  will  reveal 
the  uterus ; 

Acupuncture  will  give  no  pain.1 


IF  IT  BE  INVERSION'. 

The  prohe  will  be  arrested  at  the 
neck  ; 

Conjoined  manipulation  will  reveal  a 
ring  where  the  uterus  should  he  ; 

Rectal  examination  will  not  reveal  the 
uterus  in  situ ; 

Recto-vesical  exploration  will  not  re- 
veal the  uterus  ; 

Acupuncture  will  give  pain. 


In  certain  very  rare  cases,  a  large  fibrous  tumor  growing  from  one  lip 
of  the  cervix,  will  lead  to  the  belief  in  inversion  in  the  following  manner  : 
the  pedicle  setting  up  inflammation  in  the  cervical  canal,  complete  adhe- 
sion takes  place,  so  that  a  probe  can  nowhere  be  passed.     An  examination 


Fir,.  200. 


Fig.  201. 


Polypus 


Inversion. 


of  Fig.  200  will  readily  explain  how  such  a  state  of  things  might  arise  and 
prove  exceedingly  perplexing.  I  have  seen  two  such  cases,  one  with  Dr. 
Byrne,  of  Brooklyn,  and  another  with  Dr.  Ross  at  my  clinique,  in  both  of 
which  recognition  of  the  presence  of  the  uterine  body  above,  emboldened 


»  Gueniot,  Arch.  Gen.  deMM.,  18(58,  t.  ii.  p.  393. 


460 


INVERSION    OP    THE    UTERUS. 


me  to  work  the  probe  through  the  tissue  around  the  pedicle  of  the  growth, 
causing  it  to  enter  the  uterus,  and  thus  prove  incontestably  the  nature  of 
the  case. 

Should  the  inversion  be  incomplete,  diagnosis  will  always  prove  difficult, 
and  in  fat  women  particularly  so.  Differentiation  from  a  fibrous  tumor 
will  depend  upon  the  following  signs  : — 


IF   IT    BE  A  FIBROID  GROWTH. 

The  probe  will  show  increase  of  uterine 
cavity  ; 

Conjoined  manipulation  and  Simon's 
method  will  reveal  rotund  body  of  uterus; 

It  will  have  come  on  very  gradually  ; 

It  will  have  no  reference  to  parturition; 

Acupuncture  is  painless. 


IF  IT  BE  PARTIAL  INVERSION. 

The  probe  will  show  diminution  of 
uterine  cavity  ; 

Conjoined  manipulation  and  Simon's 
method  will  reveal  small  abdominal  ring; 

It  will  have  occurred  more  suddenly  ; 

It  usually  follows  parturition  ; 

Acupuncture  gives  pain. 


Fig.  202. 


Fig.  203. 


Fibrous  polypus. 


Partial  inversion. 


Course,  Duration,  and  Termination — All  these  are  very  variable.  The 
accident  occurring  after  delivery  may  rapidly,  unless  relieved,  produce 
death  by  hemorrhage  and  exhaustion ;  or  it  may  continue  for  many  years, 
giving  very  little  annoyance;  or,  again,  it  may  render  the  life  of  the  pa- 
tient miserable  on  account  of  hemorrhage  and  other  attending  symptoms, 
and  nevertheless  last  for  years.  As  a  rule,  it  may  be  stated  that  inversion 
continues  until  relieved  by  treatment,  and  yet  even  this  is  not  without  ex- 
ceptions. The  womb  has  been  known  under  these  circumstances  to  replace 
itself  by  its  own  contractions,  years  after  its  occurrence,  when  the  acci- 
dent has  happened  after  delivery.  Twelve  such  cases  have  now  been 
placed  upon  record:  three  by  Meigs,1  and  one  by  each  of  the  following 
observers:  Spiegelberg,2  Leroux,2  De  la  Barre,2  Thatcher,2  Rendu,2  Shaw,2 

1  Obstetrics. 

2  Article  by  Prof.  Spiegelberg,  "  Archiv  fiir  Gynakologie,"  Am.  Journ.  Obstet., 
Aug.  1873. 


PROGNOSIS.  461 

Beaudelocque,1  Foujen,2  and  Iluckins.3  Even  admitting  the  undoubted 
authenticity  of  these  cases,  spontaneous  reduction  must  be  regarded  only 
as  a  curiosity,  and  not  as  a  process  to  be  anticipated. 

Prognosis The  prognosis  of  chronic  inversion  is  at  all  times  grave. 

Repeated  and  prolonged  hemorrhages  prostrate  the  patient,  and  expose 
her  to  all  the  risks  of  the  worst  forms  of  uterine  polypus.  But  not  only  is 
she  exposed  to  dangers  inherent  to  the  displacement  i'rom  which  she  suf- 
fers ;  those  attendant  upon  an  erroneous  diagnosis  are  very  great.  To  one 
alive  to  the  possibility  of  confounding  the  condition  with  fibrous  polypus, 
the  methods  of  differentiation  are  numerous  and  reliable  ;  but  to  the  rapid 
and  careless  diagnostician,  who  does  not  allow  the  possibility  of  error  to 
enter  his  mind,  and  consequently  does  not  carefully  weigh  the  evidence, 
there  is  a  great  likelihood  of  it. 

One  who  is  aware  of  the  great  frequency  with  which  amputation  of  the 
inverted  uterus  has  been  practised,  under  the  impression  that  a  fibrous 
polypus  was  being  removed,  cannot  but  wonder  that  errors  of  diagnosis 
have  so  often  occurred,  when  so  many  methods  of  differentiation  were  at 
command.  The  explanation  is  that  to  which  I  have  referred,  namely, 
that  the  possibility  of  error  was  not  entertained.  Out  of  fifty-eight  cases 
of  inversion  of  which  a  report  is  given  in  the  "  Beitraege  zur  Geburtskunde 
und  Gynakologie,"  and  in  which  amputation  was  practised,  seven  were 
mistaken  for  polypi. 

I  have  treated  personally  nine  cases  of  inversion,  of  which  six  resulted 
from  parturition  and  three  from  traction  by  sessile  polypi.  Of  these,  seven 
were  cured  by  replacement ;  one,  in  the  case  of  a  very  old  and  feeble  wo- 
man, was  left  unreplaced,  after  removal  of  a  sessile  fibroid,  which  gave 
complete  relief;,  and  one  case  after  replacement  ended  fatally  from  perito- 
nitis. 

Even  where  a  correct  diagnosis  has  been  made,  still  another  danger 
menaces  the  patient :  that  of  rupture  of  the  vagina  in  attempts  at  reduc- 
tion of  the  inverted  organ.  A  small  hand,  a  cautious,  unexcitable  mind, 
and  constant  vigilance  during  all  the  efforts  by  taxis,  must  be  combined 
with  thorough  knowledge  of  the  subject,  to  avoid  this  imminent  danger. 
Even  with  this  combination,  it  is  a  matter  of  surprise  to  me,  from  my 
experience  with  these  cases,  that  the  accident  has  not  occurred  much 
oftener.  I  confess  that  I  should  prefer  to  trust  a  patient  in  whom  I  felt 
great  interest  to  the  operation  of  abdominal  section,  which  is  hereafter 
described,  than  to  that  of  prolonged  taxis  at  the  hands  of  a  rough,  unintel- 
ligent, and  inexperienced  practitioner.  To  one  thinking  upon  this  subject 
for  the  first  time,  this  position  will  appear  exaggerated  and  indefensible  ; 
but  I  assume  it  after  mature  reflection. 

1  Daillez,  Thesis.  3  Weiss,  Des  Reductions  de  l'Inversion,  etc. 

8  Letter  to  author  from  Dr.  Jason  Huckins,  of  Maine,  U.  S. 


462  INVERSION    OP    THE    UTERUS. 

When  the  prospect  of  returning  the  uterus  seems  brightest,  the  practi- 
tioner is  sometimes  disappointed  by  the  existence  of  adhesions.  Thus 
Velpeau,1  after  the  removal  of  a  polypus  attached  to  an  inverted  uterus, 
was  completely  foiled  in  restoring  it,  and  the  patient  died  from  peritonitis. 

Treatment. — In  the  treatment  of  inversion,  three  methods  may  be 
adopted. 

1st.  The  organ  may  be  left  in  malposition  ;  hemorrhage  being  controlled 
by  hemostatic  means. 

2d.  The  inversion  may  be  reduced  by  taxis,  by  elastic  vaginal  pressure, 
or  by  a  combination  of  the  two. 

3d.  All  these  failing  to  give  relief,  the  uterus  may  be  amputated. 

Methods  of  Checking  Hemorrhage,  the  Uterus  being  left  in  sitfi. — 
Should  the  operator  fail  in  repeated  attempts  at  reduction,  it  becomes  a 
question  whether  he  should  amputate  the  displaced  organ  or  leave  it  in  its 
abnormal  position  and  endeavor  to  combat  the  evils  resulting.  The  greatest 
of  these  is  unquestionably  hemorrhage,  which  steadily  exhausts  the  patient; 
but  others  of  less  moment  arise  from  dragging  of  the  uterus  upon  its  liga- 
ments and  the  mechanical  inconvenience  of  a  tumor  in  the  vagina.  If  the 
patient  be  near  the  menopause,  both  of  these  may  diminish  by  atrophy 
and  cessation  of  menstruation.  Should  she  be  young,  artificial  means 
may,  in  a  limited  degree,  accomplish  the  same  results. 

The  most  vascular  growths,  such,  for  example,  as  hemorrhoids  and 
naevi,  may  be  diminished  in  size  and  rendered  non-hemorrhagic  by  astrin- 
gents or  caustics,  which  destroy  their  superficial  varicose  vessels  and  leave 
a  less  vascular  tissue  beneath.  The  inverted  uterus  may  be  similarly 
acted  upon,  not  only  in  checking  hemorrhage,  but  in  producing  atrophy, 
and  thus  removing,  to  a  certain  extent,  the  two  sources  of  suffering. 

Solutions  of  alum,  tannin,  persulphate  of  iron,  or  acetate  of  lead  may 
with  advantage  be  injected  into  the  vagina  so  as  to  bathe  the  uterus  freely, 
or  they  may  be  placed  in  contact  with  it  by  means  of  pledgets  of  cotton. 
Should  these  fail  in  checking  the  flow,  a  plan,  proposed  by  Aran,  of  apply- 
ing caustics  to  the  whole  bleeding  surface,  may  be  resorted  to.  The  tumor 
being  drawn  down  and  exposed  to  view  as  much  as  possible,  its  surface  is 
seared  by  the  actual  cautery  or  touched  by  potassa  cum  calce  or  the  mine- 
ral acids.  The  organ,  after  being  bathed  in  a  neutralizing  fluid,  is  then 
enveloped  in  lint,  so  as  to  protect  the  vaginal  walls,  and  placed  within  the 
pelvis.  I  have  never  seen  the  method  employed,  but  would  not  hesitate 
in  an  appropriate  case  to  venture  upon  it.  Aran  declares  that  not  only  is 
hemorrhage  checked  by  it  but  great  diminution  of  the  tumor  effected. 
The  procedure  recommends  itself  as  eminently  rational,  and  when  it  is 
remembered  that  the  only  recognized  alternative  is  amputation,  the  pro- 
priety of  giving  it  consideration  must  be  admitted. 

1  Becquerel,  op.  cit.,  p.  306. 


METHODS  OF  REPLACING  THE  UTERUS.         4G3 

Many  cases  are  on  record  in  which  the  uterine  mucous  membrane  has 
become  altered  so  as  to  resemble  skin,  and  in  which  the  patients  have 
lived  without  suffering  for  many  years.  Dr.  Alexander  H.  Stevens  had 
one  case  under  observation  for  more  than  thirty  years.  Dr.  Charles  A. 
Lee  diagnosticated  one  which  had  remained  undetected  for  twenty-five 
years ;  and  the  works  of  older  writers  offer  many  other  examples.  If  we 
can  bring  about  a  similar  condition  by  artificial  means  and  avoid  the  ope- 
ration of  ablation,  we  will  certainly  be  acting  in  the  best  interests  of  the 
patient.     It  is  for  this  purpose  that  cauterization  offers  itself  as  a  resource. 

Methods  of  Replacing  the    Uterus It  is  not  certainly  known  whether 

the  condition  of  inversion  of  the  uterus  was  properly  understood  before 
the  time  of  Ambrose  Pare.  Since  his  epoch  it  has  been  fully  described 
by  his  successors,  and  all  its  pathological  features,  its  various  symptoms, 
and  its  manifold  dangers,  have  been  thoroughly  appreciated.  From  the 
time  of  Pare,  who  lived  about  the  middle  of  the  seventeenth  century,  to 
our  own,  although  great  advances  were  made  in  the  scientific  depart- 
ment of  the  subject,  very  little  was  attained  in  the  way  of  treatment. 
The  possibility  of  replacing  by  taxis  a  uterus  recently  inverted  was  known, 
but  for  cases  in  which  the  organ  had  been  displaced  for  years,  or  even  for 
months,  no  resource  existed  except  amputation. 

It  is  certainly  one  of  the  many  triumphs  of  which  the  gynecology  of 
the  nineteenth  century  can  boast,  that  this  accident  has  been  proved  to  be 
amenable  to  conservative  measures,  and  that  taxis  has  been  shown  to  be 
capable  of  effecting  a  cure,  and  preventing  a  resort  to  a  mutilating  surgi- 
cal procedure. 

So  far  as  I  have  been  able  to  ascertain,  the  first  cases  of  chronic  inver- 
sion which  were  successfully  reduced  by  taxis  are  those  mentioned  by 
Colombat1  in  the  following  passage  :  "  Dr.  Daillez2  reports  in  his  disser- 
tation that  the  surgeon,  Labarre  De  Benzeville,  had  effected  the  reduction 
as  late  as  the  eighth  month,  and  Baudelocque  after  eight  years."  In  later 
times  the  first  successful  case  occurred  in  1847.3  The  inversion  had  lasted 
more  than  a  year,  when  M.  Valentin,  by  introducing  one  hand  into  the 
vagina,  and  making  counter-pressure  by  the  other  over  the  abdomen,  suc- 
ceeded in  reducing  the  displaced  fundus  in  ten  minutes.  In  1852,  Mr. 
Canney3  in  the  same  manner  effected  reduction  in  a  case  of  five  months' 
standing,  and  in  the  same  year  M.  Barrier*  accomplished  it  in  one  which 
had  existed  for  fifteen  months. 

Up  to  the  year  1858,  the  reposition  of  inverted  uteri  may  be  said  to 
have  been  limited  to  replacement,  within  short  periods  after  parturition. 
It  is  true  that  occasional  cases   had   occurred  in  which  chronic  inversion 

1  Colombat,  Am.  ed.,  p.  186.  2  Daillez's  Thesis  appeared  in  1803. 

3  Quoted  from  Ranking's  Abstract,  vol.  7,  by  G.  Hewitt. 

4  Courty,  Mai.  de  1' Uterus,  p.  707. 


464 


INVERSION    OF    THE    UTERUS. 


had  been  overcome  by  taxis  and  pressure,  but  these  held  the  position  of 
accidental  and  anomalous  feats  in  treatment,  not  that  of  systematic  pro- 
cedures, which  it  was  incumbent  upon  the  practitioner  to  essay  in  every 
case.  At  this  period  two  cases  of  chronic  inversion  were  reduced,  one  of 
twelve  years'  standing  by  Prof.  Tyler  Smith,  of  London,  by  elastic  pres- 
sure and  taxis;  the  other  of  almost  six  months'  standing  by  Prof.  James 
P.  White,  of  Buffalo,  U.  S.,  by  taxis  alone.  Each  of  these  gentlemen 
worked  without  the  knowledge  of  what  the  other  was  doing ;  and  to  them 
belongs  the  great  credit  of  having  systematized,  and  made  subservient  to 
science  and  humanity,  a  method  which  before  had  been  practised  in  a 
loose  and  desultory  manner.  Soon  after  their  publications,  cases  of  cure 
affected  by  taxis  alone,  or  combined  with  pressure  by  bags  of  air  or  water 
placed  in  the  vagina,  were  rapidly  reported  from  different  parts  of  the 
world.  Most  notable  among  these  were  the  cases  of  Noeggerath,  of  13 
years'  standing ;  Teale,  of  2^  years  ;  West,  of  1  year ;  White  of  15 
years ;  and  Bockendahl,  of  6  years.  When  it  is  stated  that  all  these 
occurred  in  1859,  it  will  be  fully  appreciated  how  great  an  impetus  was 
given  to  this  subject  by  the  successes  of  Smith  and  White.  Within  the 
past  ten  years  cures  have  multiplied  so  rapidly  as  to  preclude  the  mention 
of  individual  cases  in  a  work  of  the  character  of  this  ;  and,  although  I 
cannot  go  so  far  as  to  endorse  the  sanguine  prediction  of  White,  made  in 
1872,  that  "well  directed  pressure  upon  the  fundus,  if  continued  long 
enough,  will,  in  all  cases  where  there  are  no  adhesions,  result  in  restora- 
tion or  reposition,"  I  do  believe  that  the  day  has  passed  when  any  prac- 
titioner would  be  held  blameless  by  a  jury  of  his  peers,  who  has  either  left 
untouched,  or  amputated  a  uterus  in  the  condition  of  chronic  inversion 
without  some  special  reason  apart  from  the  mere  displacement  itself. 

The  best  methods  at  our  command  for  replacing  an  inverted  uterus  I 
shall  now  proceed  to  describe,  premising  this  description  with  the  state- 
ment that  I  do  not  propose  to  mention  all  methods  which  have  been 
adopted,  but  only  those  which  are  most  worthy  of  reliance.  They  may 
thus  be  presented  at  a  glance: — 

Elastic  pressure  by  vaginal  stem  and  cup  or  bulb; 

Elastic  pressure  by  vaginal  water-bag  combined 
with  taxis ; 

Elastic  pressure  by  vaginal  water-bags  alone ; 

A  stream  of  cold  water. 

Manipulation  by  Viardel's  method  ; 

"  "  Emmet's  " 

"  "   Barrier's  " 

"  "  Noeggerath's  " 

"  "  Courty's  " 

"  "  Thomas's  " 

«  "   White's  '« 


Methods  for  effecting 
gradual  reduction 


Methods  for  effecting    , 
rapid  reduction 


GRADUAL    REDUCTION    BY    REPOSITOR. 


405 


None  of  these  methods  are  free  from  danger;  in  several  cases  even 
elastic  pressure  has  excited  fatal  peritonitis.  Hut  gradual  reposition  is 
certainly  much  safer  than  rapid  reduction. 

Before  the  practice  of  any  of  them  certain  preparatory  measures  calcu- 
lated to  relax  the  cervical  parenchyma,  or  render  its  resistance  less  de- 
cided, may  be  essayed.  One  of  these  is  the  use  of  belladonna  by  the 
vagina  in  the  form  of  vaginal  injections  of  the  infusion,  of  ointment 
smeared  around  the  uterine  neck,  or  of  hypodermic  injection  ;  or  by  the 
rectum  in  form  of  suppository.  The  other  is  the  making  of  two  or 
three  longitudinal  incisions  through  the  superficial  layers  of  the  paren- 
chyma of  the  neck.  This  method  is  a  very  old  one,  dating  back  to  Millot1 
in  1773.  Since  his  time  it  has  been  repeatedly  advised  ;  for  example,  by 
Colombat,  Gross,  Sims,  Barnes,  and  others.  Of  the  benefit  of  the  first  of 
these  methods  there  is  little  doubt ;  of  that  of  the  second  there  is  none. 

Gradual  Reduction  by  Repositor. — This  method  dates  back  to  Von 
Siebold,2  who  employed  a  curved  stem  surmounted  by  a  fine  sponge,  the 

Fig.  204. 


Cup  and  stem  for  making  continuous  pressure  in  replacing  the  inverted  uterus. 

stem  being  held  in  situ  by  a  T-bandage.  After  him  it  was  repeatedly 
and  successfully  employed,  and  to-day  it  is  coming  again  into  favor, 
having  been  very  recently  recommended  by  Drs.  Hicks  and   Barnes,  of 


1  Taylor,  op.  cit. 
30 


2  Ch.  F.  Weiss,  Paris,  op.  cit. 


466  INVERSION  OF  THE  UTERUS. 

London.  The  former  employs  a  solid  stethoscope,  the  large  extremity 
covered  hy  India-ruhber ;  the  latter,  a  hollow  caoutchouc  cup,  fixed  to  a 
curved  stem.     Both  of  these  are  supported  by  a  T-bandage. 

Before  the  cup  is  adjusted,  a  long  compress,  consisting  of  a  bag  of 
muslin  stuffed  loosely  with  cotton,  should  be  placed  across  the  hypogas- 
trium,  so  as  to  extend  from  the  anterior  superior  spinous  process  of  one 
ilium  to  the  other,  and  to  lie  just  above  the  symphysis  pubis.  This 
should  be  fixed  in  position  by  a  band  of  adhesive  plaster  made  to  encircle 
the  body  entirely.  The  compress,  being  about  eight  inches  in  circum- 
ference, forms  a  firm  ridge  across  the  pelvis,  and  furnishes  counter-pres- 
sure against  the  retreating  uterus.  The  bands  represented  as  attached  to 
the  stem  of  the  instrument  may  consist  of  India-rubber  tubing  or  of  India- 
rubber  elastic  bands,  by  which  gentle,  steady,  and  gradually  increasing 
pressure  may  be  kept  up. 

This  constitutes  one  of  the  best,  if  not  the  very  best,  of  all  the  means 
at  our  disposal  for  effecting  gradual  reduction  of  the  inverted  uterus.  One 
point  requires  special  attention ;  sometimes,  when  the  vagina  is  abnor- 
mally voluminous,  the  uterus  gets  out  of  the  line  of  pressure,  it  bends 
upon  itself  above  the  edges  of  the  cup,  and  not  only  does  the  pressure 
exerted  accomplish  no  good — it  absolutely  does  harm,  and  creates  the 
danger  of  inflammation  of  the  tissue  of  the  uterus.  This  should  be  pre- 
vented by  tamponing  around  the  cup,  after  it  is  adjusted,  with  carbolized 
cotton,  as  explained  in  connection  with  elastic  pressure  by  the  water-bag. 

The  force  exerted  by  the  elastic  bands  should  not  be  great,  for  we  should 
look  for  the  desired  result  not  to  great  but  to  gradual  and  steadily  sus- 
tained pressure. 

Elastic  Pressure  by  Vaginal    Water-bag The  demonstration  of  the 

important  fact,  the  most  important,  indeed,  connected  with  this  subject, 
that  elastic  pressure  was  capable  of  greatly  aiding  reposition  of  an  inverted 
uterus,  belongs  to  the  late  Dr.  Tyler  Smith.  I  say  "  greatly  aiding,"  for 
he  combined  taxis  with  it.  It  was  left  for  Bockendahl,  of  Germany,  to 
prove  that  it  could  effect  reduction  unaided.  Smith's  plan  consists  in 
passing  the  hand  into  the  vagina,  night  and  morning,  and  kneading  the 
uterus  for  ten  minutes,  and  during  all  the  intervening  period  keeping  an 
air  pessary  in  the  canal.  Bockendahl  simply  trusts  to  elastic  pressure 
alone,  thus  making  an  important  improvement  upon  Smith's  plan. 

The  best  method  for  employing  elastic  pressure  I  have  found  to  be  this : 
Pass  a  Sims'  speculum  and  tampon  around  the  uterus  firmly  with  carbo- 
lized cotton  soaked  in  glycerine,  so  as  to  keep  it  from  slipping  out  of  the 
line  of  pressure.  Then  introduce  an  India-rubber  bag,  and  fill  it  with 
water.  Cut  a  strip  of  adhesive  pkister  two  and  a  half  inches  wide,  and  of 
sufficient  length  to  extend  from  the  lumbar  region  between  the  thighs  of 
the  patient  and  as  high  up  as  the  navel.  Two  holes  should  be  cut  in  it, 
one  for  the  tube  of  the  rubber  bag  to  pass  through,  the  other  to  leave  the 


RAPID    REDUCTION    BY    TAXIS.  407 

urethra  free.  After  the  bag  is  introduced  into  the  vagina,  this  strip  of 
plaster  is  heated  and  attached  to  the  surface.  The  bag  may  afterwards  be 
rendered  more  tense  by  pumping  in  water,  or  the  amount  of  its  contents 
may  be  diminished  by  turning  the  stopcock,  which  prevents  its  escape. 
"While  the  method  is  in  operation,  the  patient  should  be  kept  in  bed,  and 
all  pain  quieted  by  the  use  of  opium.  The  bladder  should  be  emptied  by 
the  catheter,  and  the  bowels,  previously  thoroughly  evacuated,  be  kept 
constipated. 

A  Stream  of  Cold  Water This  method  has  not  been  sufficiently  tested 

to  command  confidence,  but  it  is  worthy  of  mention  an.l  consideration. 
Dr.  Charles  Martin,1  of  France,  succeeded  in  effecting  reduction  in  a  case 
which  proved  rebellious  to  other  means  by  this,  which  he  tried  in  the  fol- 
lowing manner :  he  introduced  the  speculum  around  the  inverted  uterus 
twice  a  day  and  threw  upon  the  fundus,  with  force,  by  means  of  a  syringe, 
a  stream  of  cold  water.  Then  filling  the  speculum  with  cold  water,  he 
kept  the  uterus  immersed  for  three  or  four  minutes.  My  impression  is 
that,  simple  as  this  method  is,  we  shall  hear  of  it  again. 

There  is  no  limit  to  the  time  during  which  efforts  at  gradual  reduction 
may  be  persevered  in.  Such  a  limit  is  established  solely  by  the  patient's 
tolerance  of  the  method  tried.  A  case  is  mentioned  in  this  chapter  in 
which  elastic  pressure  was  kept  up  for  eighteen  days  with  successful  result. 
Sometimes,  however,  the  patient  cannot  tolerate  elastic  pressure,  or  that 
by  a  repositor,  for  symptoms  of  peritonitis  result  from  their  use.  Then  it 
is  that  anaesthesia  and  rapid  reduction  offer  themselves  as  valuable  re- 
sources. 

Rapid  Reduction  by  the  Old  Methods  of  Taxis Taxis  has  been  prac- 
tised for  the  reduction  of  chronic  inversion  certainly  since  the  beginning  of 
this  century,  and  perhaps  before  that  time,  in  two  entirely  distinct  methods. 
First,  the  manipulations  of  the  operator  are  directed  to  the  constricting 
cervix,  in  order  to  overcome  resistance  there,  and  to  return  first  the  parts 
which  last  escaped.  Second,  these  manipulations  are  directed  to  the  body, 
in  order  to  return  first  the  parts  which  escaped  first.  The  first  of  these 
methods  is  thus  described  by  Capuron  :2  "  If  the  orifice  be  not  sufficiently 
dilated  to  allow  the  inverted  portion  to  return  easily,  it  is  a  better  plan  to 
take  the  tumor  in  the  palm  of  the  hand,  with  the  fingers  distributed  around 
its  pedicle,  and  to  reduce  first  the  portion  which  was  inverted  last,  as  if 
we  were  dealing  with  a  hernia."  "  We  encounter  at  this  point,"  says 
Aran,3  "two  opinions  which  have  arisen  in  relation  to  the  reduction  of 
the  uterus  inverted  during  labor ;  one  party  desiring  to  return  first  the 
parts  which  escaped  last,  subjecting  the  uterus  to  a  general  compression, 
so    as    to  soften    it  to  a   certain   extent  and  force  it  to  pass  the  orifice 

1  Gaz.  des  Hop.,  1853.  i  Mai.  des  Femmes,  2d  ed.,  p.  510. 

3  Mai.  de  1' Uterus,  p.  901. 


4G8  INVERSION  OF  THE  UTERUS. 

little  by  little,  commencing  with  the  least  voluminous  parts 

Arrived  at  the  tumor,  if  the  operator  wishes  to  employ  the  first  method, 
he  kneads  it  so  as  to  soften  it,  and  cause  it  to  pass  more  easily  through 
the  constricted  orifice  in  which  he  engages  his  fingers."  Becquerel1  de- 
scribes it  thus :  "  It  is  advisable,  as  far  as  practicable,  to  return  first  the 
parts  which  last  escaped  ;  for  in  this  way  we  dilate  in  advance  the  mus- 
cular fibres  which  oppose  reduction.  (P.  Dubois  Danyau.)  .... 
M.  Velpeau  considers  this  the  best  method." 

The  second  method  of  taxis  consists,  not  in  manipulating  the  "  con- 
stricted orifice  in  which  he  engages  his  fingers,"  so  as  to  "  dilate  in  advance 
the  muscular  fibres  which  oppose  reduction,"  as  Aran  and  Becquerel 
express  it ;  but  in  dimpling  or  indenting  the  fundus  itself,  so  as  to  make 
of  the  indented  or  invaginated  portion  a  species  of  wedge,  which  is  forced 
into  the  cervical  constriction.  In  recent  cases  of  inversion,  occurring,  as 
the  vast  majority  of  these  cases  do,  after  labor,  350  out  of  400  reported 
by  Crosse  having  done  so,  the  centre  of  the  fundus  may  be  indented  and 
carried  up  through  the  cervical  canal ;  and  even  in  chronic  cases  such  an 
invagination  has  been  attempted.  My  impression  is  that  the  manipula- 
tions practised  on  the  fundus  in  chronic  cases  act  not  in  this  way,  but  in 
overcoming  cervical  resistance,  and  thus  accomplishing  in  a  more  indirect 
and  imperfect  way  what  the  French  method,  styled  the  method  of  Viardel 
by  Becquerel,  does  by  engagement  of  the  fingers  within,  and  direct  expan- 
sion of,  the  cervical  constriction.  It  is  scarcely  applicable  to  other  than 
recent  cases. 

T<he  diagnosis  having  been  clearly  made  and  reduction  determined  upon, 
the  bowels  and  bladder  should  be  emptied,  and  the  patient  put  under  the 
influence  of  an  anaesthetic,  and  laid  on  her  back  upon  a  strong  table.  The 
operator  should  always  be  attended  by  three  or  four  reliable  counsellors, 
upon  whom  he  may  call  not  only  for  advice  but  physical  aid.  As  the 
late  Prof.  Elliot  has  pointed  out,  the  strength  of  one  man  will  often  fail  to 
accomplish  what  that  of  several,  replacing  each  other  in  rapid  succession, 
will  readily  effect.  Having  thoroughly  oiled  one  hand,  the  nails  of  which 
have  been  pared,  the  operator  should  slowly  dilate  the  vagina  so  as  to 
introduce  it,  and  grasp  in  its  palm  the  entire  tumor.  The  other  hand 
should  be  laid  upon  the  abdomen  so  as  to  press  just  over  the  ring  which 
marks  the  non-inverted  cervix,  and  oppose  the  force  exerted  through  the 
vagina,  so  as  to  prevent  too  great  stretching  of  this  canal. 

In  a  case  of  four  years'  standing,  which  I  attended  with  Dr.  Joseph 
"Worster,  of  this  city,  and  which  had  been  subjected  to  eight  attempts 
previous  to  my  seeing  it,  each  varying  in  duration  from  two  to  three 
hours,  I  suggested  substituting  for  the  hand  a  cone  of  boxwood  four  inches 
long.     The  patient  being  very  thin,  this  could  readily  be  inserted  into  the 

1  Mai.  de  l'Utfirus,  tome  2,  p.  314. 


METHODS  OF  REPLACING  THE  UTERUS.         409 

abdominal  ring  of  the  uterus,  and  it  was  gradually  forced  down  info  the 
inverted  fundus  lor  such  a  distance  as  to  dilate  the  cervix  and  allow  repo- 
sition. Since  the  experience  gained  in  that  case  I  have  always  employed 
this  abdominal  plug  for  counter-pressure,  except  in  fat  women,  and  this 
course  has  likewise  been  adopted  by  Byrne  and  others. 

In  attempting  reduction  by  the  hand  in  the  vagina  clasping  the  inverted 
uterus,  the  operator  should  not  adhere  too  long  to  one  [dan  of  manipula- 
tion, but  try  one  after  the  other  the  methods  of  manipulation  which  will 
now  be  mentioned. 

Emmet's  Method This  consists  in  giving  to  the  finger  encircling  the 

cervix  a  decided  motion  of  extension,  while  counter-pressure  is  actively 
kept  up  by  the  fingers  over  the  abdominal  ring  so  as  to  expand  this  by  the 
conjoined  action  of  the  two  hands.  I  had  supposed  this  method  to  be 
identical  with  that  of  Viardel,  but  its  proposer  declares  it  to  be  different 
from  it  in  many  essential  respects,  and  speaks  highly  of  its  merits.  A 
full  exposition  of  it  will  be  found  in  his  work  upon  "  The  Principles  and 
Practice  of  Gynecology." 

Barrier's  Method  consists  in  spreading  the  four  fingers  around  the 
uterus,  pressing  the  thumb  against  the  fundus,  and  forcing  the  neck  against 
the  curve  of  the  sacrum  as  a  point  of  resistance. 

Noeygerath's  Method  consists  in  placing  the  index  finger  upon  one  horn 
of  the  uterus,  the  thumb  upon  the  other,  and  so  compressing  as  to  invert 
one  or  both  cornua.  Before  reinversion  of  the  neck  it  should  not  be  tried. 
For  reducing  the  body  after  the  neck  has  yielded  it  is  a  most  valuable 
plan.  I  have  succeeded  by  it  in  three  out  of  five  cases  which  I  have 
treated. 

Courty's  Method  consists  in  passing  the  index  and  middle  finger  up  the 
rectum,  dipping  them  into  the  cervical  ring,  and  thus  gaining  a  point  of 
resistance.  It  is  one  of  the  best  at  our  command,  and  may  be  combined 
with  Noeggerath's  method,  one  being  directed  to  reduction  of  the  neck, 
the  other  to  that  of  the  body. 

Thomas's  Method  consists  in  abdominal  section  over  the  cervical  ring, 
dilatation  with  a  steel  instrument,  made  like  a  glove-stretcher,  and  reposi- 
tion of  the  inverted  uterus  by  any  one  of  the  methods  mentioned,  by  the 
hand  in  the  vagina.      Fig.  205  will  render  this  clear. 

This  procedure,  let  it  be  remembered,  is  not  offered  as  a  method  of 
treating  inversion  of  the  uterus,  but  as  a  substitute  for  amputation.  Few 
cases  will,  I  think,  resist  elastic  pressure  and  judicious  taxis ;  but  that 
some  will  do  so  cannot  be  questioned.  It  is  to  save  these  few  cases  from 
amputation  that  I  suggest  abdominal  section. 

One  of  the  cases  operated  on  in  this  way  has  proved  fatal.  Let  it  not 
be  forgotten  that  a  certain  number  of  those  cases  treated  by  elastic  pres- 
sure and  by  taxis  likewise  do  so,  for,  as  in  my  second  case,  these  operations 
are  often  performed  upon  exsanguinated  women  whose  blood  is  impove- 


470 


INVERSION    OP    THE    UTERUS. 


rished.  One  instance  of  death  after  reduction  by  elastic  pressure  is  re- 
corded by  Dr.  Tait  in  the  eleventh  volume  of  the  London  Obstetrical 
Transactions,  while  one  of  the  earliest  cases  on  record  reduced  by  taxis, 
that  of  Dr.  White,  of  Buffalo,  likewise  ended  fatally. 


Fig.  205 


Replacement  of  uterus  by  dilatation  through  abdomen. 


If  a  case  should  prove  rebellious  to  taxis  repeatedly  and  intelligently 
applied,  and  to  prolonged  and  powerful  elastic  pressure,  what  is  to  be  done? 
Only  two  courses  have  been  open  to  us ;  one  to  leave  the  case  unrelieved, 
the  other  to  perform  amputation.  In  an  elaborate  report  of  cases  of  in- 
version given  in  the  American  Journal  of  Obstetrics  for  August,  18G8, 
the  results  in  fifty-eight  eases  of  amputation  are  given.  By  this  statement 
it  will  be  seen  that  nearly  one-third  of  all  operated  upon  died,  and  let  it 
not  be  forgotten  that  this  number  died,  not  in  being  cured,  not  in  an 
effort,  even,  at  attaining  perfect  health,  but  in  an  attempt  at  purchasing 
immunity  from  a  series  of  dangerous  and  annoying  symptoms  at  the  price 
of  that  organ  of  which  Hippocrates  says,  "Propter  uterum  est  mulier." 

It  is  incumbent  on  me  to  state  that  this  method  has  not  received  the 
endorsement  of  the  profession.  Appreciating  this  I  should  have  omitted 
it  entirely  from  enumeration  here,  did  I  not  feel  that  in  the  future  it  will 
receive  more  favorable  consideration  and  prove  of  real  value. 

The  use  of  a  repositor  by  which  to  make  direct  pressure  and  aid  in  re- 
duction has  been  resorted  to  by  Depaul  and  others.  Prof.  J.  P.  White 
has  successfully  employed  one  which  by  its  simplicity  and  efficacy  makes 
it  worthy  of  especial  mention.  Fig.  206  shows  this  instrument,  and,  like- 
wise, makes  evident  the  method  of  reduction  which  the  experience  of  nine 
cases  extending  over  a  period  of  fifteen  years  has  led  him  to  adopt. 


METHODS    OF    AMPUTATING. 


471 


Excellent  repositors  have  likewise  been  invented  by  Avclingand  Byrne. 
The  latter  of*  these  is  constructed  upon  the  best  mechanical  principle  which 
has  ever  been  applied  to  this  process,  consisting  of  a  cup  which  is  made 
shallower  and  less  capacious  by  the  action  of  a  screw  at  its  lower  extremity, 
as  the  inverted  uterus  gradually  returns  to  its  place.  I  have  employed  it 
with  perfect  success  in  one  case,  and  esteem  it  very  highly. 


Fig.  206. 


Rapid  reduction  by  White's  method.     Operator  grasps  uterus,  a,  aud  presses  his  chest  agaiust 
spiral  spriug,  </,/,  which  forces  cup  of  repositor  agaiust  fuudus. 

It  is  impossible  to  set  an  absolute  limit  to  the  time  which  should  be 
allotted  to  one  attempt  at  immediate  reduction,  but  these  efforts  cannot  be 
persisted  in  much  longer  than  one  or  two  hours  without  great  danger  of 
cellulitis  or  peritonitis.  It  is  true  that  numbers  of  successful  cases  are  on 
record  in  which  from  three  to  five  hours  have  been  spent  in  continuous 
exertion  before  success  was  accomplished,  and  in  which  no  unfavorable 
symptoms  have  arisen;  but  a  safer  and  more  judicious  course  would  be  to 
desist  after  a  reasonable  effort,  secure  what  has  been  gained  by  placing  a 
caoutchouc  bag  in  the  vagina,  or  closing  the  os  uteri  by  silver  sutures  as 
practised  by  Emmet,  after  the  method  shown  in  Fig.  207,  administer  a 
large  dose  of  opium,  and  make  another  attempt  in  thirty-six  or  forty-eight 
hours.  Manipulation  should  then  be  cautiously  repeated  for  about  the 
same  period,  and  again,  in  case  of  failure,  followed  by  the  air  bag,  or 
closure  by  suture. 

Methods  of  Amputating Although  it  cannot  be  denied  that  instances 

may  present  themselves  in  which,  from  impossibility  of  returning  the 
inverted   uterus,  removal  of  the  whole  organ  is  indicated,  it  is  equally 


472 


INVERSION    OF    THE    UTERUS. 


undeniable  that  the  operation  has  been  resorted  to  very  often  upon  insuffi- 
cient grounds  and  before  efforts  at  reduction  had  been  fairly  tried.  Tyler 
Smith  succeeded  after  persevering  with  elastic  pressure  for  eight  days, 


Fig.  207. 


Partially  restored  uterus  sustained  by  closure  of  os  externum      (Emmet.) 

and  Dr.  F.  A.  Ramsay,1  of  Knoxville,  Tennessee,  after  seventeen  or 
eighteen  days  of  effort.  Does  any  one  doubt  that  in  the  hands  of  many 
less  persevering  practitioners  both  these  cases  would  have  been  treated  by 
amputation  before  success  was  attained?  Amputation  of  the  inverted 
uterus  will  surely  be  less  frequently  performed  in  the  future  than  it  has 
been  in  the  past.  It  is  destined  to  assume  among  operative  procedures 
its  proper  place  as  a  last  resort.  In  addition  to  its  own  manifest  and 
inherent  dangers  it  must  ever  present  these  great  objections: — 

1st.  Hernia  of  the  abdominal  or  pelvic  viscera  may  have  taken  place 
into  the  inverted  sac; 

2d.  It  frequently  produces  emansio-mensium  and  its  train  of  evils; 

3d.   It  necessarily  results  in  sterility. 

It  is  impossible  to  conceive  of  circumstances  which  would  justify  the 
procedure  before  full  consultation  with  the  most  able  counsel  attainable. 

Removal  of  the  uterus,  although  attended  by  great  danger,  often  ends 
in  recovery.  This  will  not  be  wondered  at  when  it  is  borne  in  mind  that 
even  tearing  away  of  the  organ  has  been  several  times  recovered  from. 
Radford,  J.  C.  Clarke,1  and  others  have  reported  cases  in  which  an   in- 


1  Taylor,  op.  cit. 


*  Dublin  Journal,  1837. 


»1 

leration 

Recovered. 

Died. 

ab 

iiudoued 

45 

33 

10 

2 

5 

3 

2 

9 

6 

3 

59 

42 

15 

o 

METHODS    OF    AMPUTATING.  473 

verted  uterus  has  sloughed  off  from  strangulation  without  a  fatal  issue,  and 
Osiander  for  many  years  showed  a  patient  in  his  lecture-room  from  whom, 
after  delivery,  the  midwife  tore  away  not  only  the  placenta  but  the  inverted 
uterus  to  which  it  was  attached.  A  case  of  similar  kind  is  recorded  in 
the  Gazette  des  Hopitaux  for  1842.  One  child  being  born,  the  midwife 
felt  the  breech  of  another  as  she  supposed.  Around  it  she  passed  a  hand- 
kerchief, pulled  with  all  her  force,  and  dragged  away  uterus  and  annex*. 
The  patient  recovered! 

A  comprehensive  view  of  the  results  of  amputation  is  presented  by  Dr. 
West  in  the  following  table: — 


Uterus  removed  by  ligature  .... 

'•  "      knife  or  (Scraseur    . 

"  "      knife  or  ecraseur,  preceded  by 

the  ligature 


Out  of  58  cases  of  amputation  collected  in  the  report  in  the  German 
journal  recently  alluded  to,  18  were  fatal — nearly  one-third. 

Should  it  be  deemed  advisable  to  resort  to  this  procedure  in  spite  of  the 
dangers  incident  to  it,  there  are  four  methods  by  which  it  may  be  per- 
formed :  the  knife  or  scissors  preceded  by  the  ligature  ;  the  ecraseur,  pre- 
ceded by  the  ligature ;  the  elastic  ligature  ;  and  the  galvano-cautery. 

Experience  proves  that  removal  of  an  inverted  uterus  by  the  knife,  or 
even  the  ecraseur,  is  likely  to  be  followed  by  profuse  and  dangerous  he- 
morrhage. To  avoid  this,  a  method  advised  by  Dr.  McClintock,  of  Dub- 
lin, may  be  adopted.  It  consists  in  the  application  of  a  strong  ligature  for 
from  two  to  three  days  before  the  operation.  This  obliterates  the  vessels, 
and,  just  about  the  time  that  decomposition  of  the  strangulated  organ  be- 
gins, amputation  is  practised.  Even  should  the  galvano-cautery  be  resorted 
to,  so  great  is  the  danger  of  immediate  and  remote  hemorrhage,  that  it  is 
advisable  to  precede  its  use  by  that  of  the  ligature  for  a  few  days.  Courty 
strongly  recommends  ligature  of  the  neck  of  the  inverted  organ  by  a  rub- 
ber ligature,  which  he  tightens  on  the  second  day  as  much  as  possible.  The 
uterus  is  amputated  by  this  on  the  twelfth  or  fourteenth  day.  During  the 
use  of  all  these  methods  pain  and  nervous  disturbance  should  be  quieted 
by  the  hypodermic  use  of  morphia,  and  septicaemia  obviated  by  antiseptic 
vaginal  injections. 

Hegar  and  Kaltenbach1  recommend  the  following  plan  for  amputation. 
Sutures  of  metal  or  silk  are  passed  through  the  cervix,  high  up,  and  tightly 
drawn  so  as  to  constrict  all  vessels,  and  completely  close  the  peritoneal 
cavity.     Then,  by  any  means  which  the  operator  may  select,  the  body  of 

1  Hegar  and  Kaltenbach,  Op.  Gyn.  p.  279. 


474  INVERSION    OF    THE    UTERUS. 

the  uterus  is  amputated.  By  this  procedure  hemorrhage  is  kept  under 
control,  and  the  parts  are  so  arranged  as  to  favor  subsequent  union. 

Removal  of  the  uterus  by  ligature  alone  should  never  be  attempted. 
Not  only  have  we  better  and  safer  means ;  statistics  prove  this  to  be  an 
especially  dangerous  method.  Out  of  33  cases  thus  operated  upon,  1 7, 
over  half,  ended  fatally. 

Resume  of  Plans  of  Treatment — Let  us  suppose  that  a  case  of  chronic 
inversion  applies  for  treatment  to  a  general  practitioner,  what  are  the 
methods  by  which  he  could  most  easily  and  safely  test  the  question  of  his 
ability  to  overcome  the  difficulty  without  resorting  to  the  aid  of  a  specialist  ? 

I  would  advise  the  following  course  as  having  these  advantages it  is  often 

equal  to  the  accomplishment  of  replacement ;  even  when  it  does  not  prove 
so,  it  is  safe;  and  it  does  not  ordinarily  alienate  the  co-operation  of  the 
patient,  as  an  injudicious  course  may  very  readily  do  by  the  discomfort 
which  it  induces. 

1st.  The  bowels  should  be  thoroughly  evacuated  by  a  course  of  mild 
cathartics ;  vaginal  irritation  and  engorgement  be  relieved  by  copious  hot 
vaginal  injections;  and  uterine  congestion,  which  always  exists,  be  over- 
come by  rest. 

2d.  Pressure  by  the  cup  and  stem  should  then  be  fully  tried  for  a  fort- 
night, hot  vaginal  injections  and  inunction  of  the  cervix  with  belladonna 
being  employed  at  the  same  time. 

3d.  Elastic  pressure  by  vaginal  water-bags  should  then  be  tried,  the 
uterus  being  kept  in  the  line  of  pressure  by  means  of  a  tampon  of  antisep- 
tic cotton  saturated  with  glycerine. 

4th.  Should  this  not  produce  good  results  in  a  week,  and  no  untoward 
symptoms  have  developed,  taxis  should  be  tried  for  a  short  time  once  or 
twice  a  day. 

5th.  Should  success  not  now  crown  his  efforts,  the  practitioner  might 
try  the  use  of  a  stream  of  cold  water  projected  against  the  inverted  fundus, 
or  this  might  be  combined  with  elastic  pressure,  taxis,  and  the  other  means 
just  mentioned. 

All  these  means  failing,  resort  to  more  radical,  efficient,  and  hazardous 
ones  will  now  become  necessary.  But  let  the  practitioner  remember  that 
so  long  as  the  temperature  and  pulse  remain  normal,  or  nearly  so,  and 
there  is  absence  of  severe  pain,  he  may  with  safety  persist  in  the  mild 
efforts  at  reduction  which  have  been  mentioned,  even  for  several  weeks. 
Should  every  general  practitioner  do  this  systematically  and  intelligently, 
few,  very  few  cases  of  this  accident  would  fall  into  the  hands  of  the  spe- 
cialist, and  a  geat  deal  of  fame  now  concentrated  upon  a  few  would  be  dis- 
tributed among  many. 

The  day  for  rapid  and  brilliant  replacements  of  the  uterus  in  condition 
of  chronic  inversion  has  passed  and  gone.  There  are  unquestionably  cases 
which  may  call  for  immediate  or  at  least  for  rapid  replacement,  and  others 


PERIUTERINE    CELLULITIS.  475 

which  will  demand  the  most  heroic  resources  of  surgery,  from  the  fact  that  all 
milder  ones  have  failed.  But  the  rule  should,  with  our  present  light  upon 
the  subject,  be  positively  and  unhesitatingly  accepted,  that  gentle,  slow, 
and  safe  methods  should  always  take  precedence  over  rapid,  harsh,  and 
dangerous  ones.  As  a  very  general  rule  time  is  here  a  matter  of  no  mo- 
ment. Certainty  of  result  and  freedom  from  danger  are  the  great  deside- 
rata. A  case  of  chronic  inversion  presenting  itself  under  the  circum- 
stances which  are  ordinarily  attendant  upon  the  condition,  the  surgeon 
who  selects  the  plan  of  rapid  over  that  of  gradual  reduction  is  exposing 
his  patient  to  risks  which  might  have  been  avoided  in  the  attainment  of  a 
result  which  would  have  been  as  likely  under  the  safe  as  under  the  dan- 
gerous course.  If  allf  goes  well  after  adoption  of  the  latter,  neither  surgeon 
nor  patient  will  question  the  wisdom  of  the  choice;  but  supposing  that  a 
fatal  issue  occurs! 

It  must  be  appreciated  that  I  do  not  undervalue  the  serious  procedures 
which  have  been  recommended  and  practised  for  obstinate  cases  of  inver- 
sion. I  would  unhesitatingly  resort  to  them  after  failure  with  safer  and 
less  efficient  procedures.  It  is  a  resort  to  them  as  a  matter  of  election, 
and  before  the  milder  means  have  been  tried,  that  I  deprecate — a  willing- 
ness to  weigh  the  safety  and  interests  of  the  patient  against  any  other 
consideration  that  I  condemn. 

As  one  looks  back  upon  his  experience  in  surgery,  he  can  see  many 
cases  which,  if  he  could  have  availed  himself  in  them  of  knowledge  which 
did  not  exist  a  few  years  ago,  would  in  all  probability  have  had  a  favora- 
ble instead  of  a  fatal  result,  and  he  feels  regret.  If  he  have  at  his  disposal 
resources  which  could  have  produced  such  a  happy  change  in  the  record, 
and  which  he  from  choice  did  not  use,  regret  is  apt,  in  the  mind  of  a 
conscientious  rman,  to  merge  painfully  into  remorse. 


CHAPTER   XXX. 

PERIUTERINE  CELLULITIS. 

History — The  history  of  this  affection  presents  one  of  those  examples, 
which  are  often  repeated  in  medical  literature,  of  a  subject  which  was 
once  understood  being  subsequently  completely  overlooked  and  forgotten. 

There  can  be  little  doubt  that  it  is  to  this  disease  that  allusion  was 
made  by  Archigenes,  who  flourished  in  the  second  century,  and  whose 
account  of  it  was  subsequently  repeated  by  Oribasius  in  the  fourth,  and 
Aetius  and  Paul  of  ^Egina  in  the  sixth  and  seventh.  The  last  two 
unquestionably  refer  to  it  under  the  head  of  "Abscess  of  the  Womb,"  for 


476  PERIUTERINE    CELLULITIS. 

in  one  passage  Paulus  especially  speaks  of  cases  in  which  the  "  aposteme 
is  seated  about  the  mouth  of  the  uterus." 

The  modern  history  of  the  subject  may  be  thus  stated  : — 

Described  by  Richard  Wiseman,'  England,  as  "Distempers 

of  the  uterus  in  childbed,"  .         .         .         .     1679 

"  Nichs.  Puzos,2  France,  as  "Depots  Laiteux,"    1743 

"  Bourdon,  a  pupil  of  Recamier,  as  "Fluctu- 

ating tumor  of  true  pelvis,"         .         .         .     1841 

"  Doherty,  Ireland,  as  "Chronic  inflammation 

of  the  appendages  of  uterus,"      .         .         .     1843 

"  Marchal  de  Calvi,  as  "  Intra-pelvic  phlegmo- 
nous abscess," 1844 

"  Churchill,3  Ireland,  as  "Abscess  of  uterine 

appendages," 1844 

"  Lever,  England, 1844 

It  will  thus  be  seen  that  after  being  appreciated,  then  entirely  forgot- 
ten, then  for  a  second  time  brought  into  notice,  the  knowledge  of  this 
affection  languished  for  nearly  two  centuries,  to  be  suddenly  restored  by 
the  efforts  of  four  investigators  who  entered  the  field  almost  simultaneously. 
It  would  be  unjust  to  a  conscientious  observer,  M.  Auguste  Nonat,  not  to 
mention  the  great  influence  which  his  writings  have  had  in  advancing  our 
knowledge  ;  but  when  he  commenced  his  investigations  in  Hopital  Cochin, 
in  1846,  the  morbid  state  which  he  subsequently  did  so  much  to  elucidate 
had  already  received  considerable  attention  in  Great  Britain. 

Definition,  Synonyms,  and  Frequency — This  disease,  which  is  now 
known  to  be  of  frequent  occurrence,  consists  in  an  inflammation  of  the 
adipose  and  areolar  tissue  lying  behind,  in  front  of,  and  at  the  sides  of  the 
uterus,  and  extending  up  between  the  layers  of  serous  membrane  which 
make  the  broad  ligaments.  It  has  been  described  by  different  writers 
under  the  following  titles  :  parametritis,  periuterine  phlegmon,  inflamma- 
tion of  the  broad  ligaments,  pelvic  abscess,  and  pelvic  cellulitis.  The  last 
term,  which  was  applied  to  it  by  Sir  James  Simpson,  indicates  the  nature 
and  seat  of  the  disease  ;  but  it  is  open  to  the  grave  objection  of  being  too 
general  in  its  application,  and  not  sufficiently  confining  within  proper 
limits  a  distinct  and  well-defined  affection. 

Anatomy "  The  sub-peritoneal  pelvic  tissue,"  says  Dr.  Savage,*  in  his 

work  on  the  Female  Pelvic  Organs,  "  fills  up  all  that  part  of  the  pelvic 
cavity  between  the  pelvic  '  roof  and  floor  of  the  pelvis,  which  is  not  occu- 

!  MeClintock,  "Diseases  of  Women,"  p.  1. 

2  Drs.  West  and  MeClintock  date  the  appearance  of  Puzos,  "  Traite"  d'Accouehe- 
ment,"  1750.  They  are  probably  in  error,  as  Bernutz  and  Nonat  both  date  it 
1743. 

8  West,  "  Diseases  of  Women,"  Am.  ed.,  p.  310. 

4  Savage,  op.  cit. 


PATHOLOGY.  477 

pied  by  the  viscera,  and  is  the  sole  bond  of*  union  between  them."  Any 
one  can  satisfy  himself  as  to  the  abundance  of  loose  cellular  tissue  in  the 
pelvis,  by  even  a  rough  dissection.  It  will  be  found  in  the  broad  liga- 
ments in  great  abundance  separating  their  contents,  between  the  vagina 
and  rectum,  the  rectum  and  sacrum,  the  uterus  and  bladder,  the  bladder 
and  abdominal  parietes,  and  investing  the  psoas  and  iliac  muscles.  The 
relations  of  the  urethra  and  rectum  to  this  tissue  are  peculiar,  each  being 
isolated  in  a  sheath  or  canal  which  may  be  removed  with  ease. 

Everywhere  around  the  pelvic  organs  cellular  tissue  exists  except  be- 
tween the  peritoneum  and  uterus.  Here  so  little  is  discoverable  that  some 
have  ventured  to  deny  its  existence,  while  all  admit  that  over  the  body  of 
that  organ  it  is  difficult  of  demonstration.  Dr.  Farre1  declares  that  along 
the  median  line  and  over  the  whole  fundus  he  has  found  the  peritoneum 
inseparable  from  the  uterus,  except  after  prolonged  maceration.  On  the 
sides  of  the  organ  and  at  the  cervix  the  connection  is  not  so  intimate,  loose 
cellular  tissue  existing  at  these  points  to  such  an  extent  as  to  permit  of 
the  investing  membrane  gliding  upon  the  uterus.  M.  Goupil,2  who  has 
made  a  special  study  of  this  tissue,  declares  that  it  is  so  small  in  amount 
at  the  point  of  contact  of  the  peritoneum  and  vagina,  and  in  front  and  rear 
of  the  uterus,  that  "  its  presence  can  scarcely  be  determined." 

Pathology — According  to  the  wide  range  given  to  the  affection  by  the 
majority  of  English  pathologists,  this  areolar  tissue  is  the  seat  of  the  disease 
under  consideration,  which  may  affect  any  or  all  of  its  parts.  Drs.  West, 
Simpson,  and  most  British  writers,  except  Dr.  Bennet,  adopt  this  view,  and 
regard  as  instances  of  the  affection  any  inflammation  of  the  cellular  tissue 
within  the  pelvis.  But  this  evidently  leads  to  great  confusion.  It  is  cer- 
tainly not  conducive  to  clearness  of  comprehension  to  blend  the  description 
of  iliac,  psoas,  and  perirectal  abscesses  with  this  disease. 

French  writers,3  on  the  contrary,  regard  as  instances  of  periuterine  cel- 
lulitis only  inflammation  of  the  cellular  tissue  of  the  broad  ligaments  and 
of  that  immediately  in  contact  with  the  uterus  at  its  junction  with  the 
vagina  and  bladder.  While  admitting  that  inflammation  originating  here 
may  spread,  by  continuity  of  structure,  to  other  areolar  tracts  in  the  pel- 
vis, they  regard  these  as  complications,  designating  them  by  different  ap- 
pellations, and  do  not  admit  them  as  elements  of  this  affection.  This  is 
the  definition  which  I  would  adopt,  and  to  express  it  clearly  have  employed 
the  term  periuterine,  in  place  of  pelvic,  cellulitis. 

Periuterine  cellulitis  has  three  stages  :  1st,  the  stage  of  active  conges- 
tion; 2d,  that  of  effusion  of  liquor  sanguinis  ;  3d,  that  of  suppuration.  In 
its  course  it  may  be  likened  to  an  ordinary  furuncle  ;  at  first  there  is  sim- 
ple congestion  accompanied  by  pain,  heat,  and  swelling;  then  liquor  san- 

1  Cyc.  Anat.  and  Phys.,  Sup.,  p.  631.  2  Becquerel,  p.  441,  vol.  i. 

3  Aran,  Mai.  de  lTterus,  p.  675. 


478  PERIUTERINE    CELLULITIS. 

guinis  is  effused,  which  creates  hardness  and  tension,  and  lastly  suppuration 
occurs,  and  ends  the  morbid  process,  unless  one  of  two  other  terminations 
takes  place.  Resolution  may  occur,  or,  in  place  of  suppuration,  the  areolar 
tissue  involved  may  be  destroyed,  as  it  so  generally  is  in  anthrax  and 
phlegmonous  erysipelas,  and  come  forth  as  a  sloughing  mass. 

The  term  phlegmon,  now  almost  obsolete  with  us,  but  still  in  use  on  the 
continent  of  Europe,  signifying  inflammation  of  areolar  tissue,  is  strictly 
applicable  to  this  affection.  Its  source  is  similar  to  that  of  areolar  inflam- 
mations in  other  parts  of  the  body,  and  its  three  stages  are  identical  with 
theirs. 

The  most  common  seat  of  periuterine  cellulitis  is  the  areolar  tissue  of 
the  broad  ligaments,  and  generally  that  of  one  side  only  is  affected. 

In  a  certain  number  of  cases  where  no  affection  of  the  areolar  tissue  of 
the  broad  ligaments  exists,  circumscribed  tumors,  in  immediate  contact 
with  the  womb,  have  long  been  noticed.  Lisfranc  supposed  them  to  be 
due  to  partial  parenchymatous  metritis,  "  engorgements,"  which  had 
resulted  in  enlargements  of  one  part  of  the  organ  ;  and  no  one  contradicted 
him  until  M.  Xonat,1  about  the  year  1849,  described  them  as  being  due 
to  phlegmonous  inflammation  in  the  areolar  tissue  immediately  around 
the  uterus,  i.  e.,  between  the  cervix  and  rectum,  the  cervix  and  bladder, 
and  immediately  by  the  side  of  the  neck.  The  existence  of  this  variety 
of  cellulitis  has  been  denied  by  M.  Bernutz,  who  sustains  his  position  by 
abundant  argument.  In  reference  to  it,  I  will  merely  say  here,  that  there 
are,  so  far  as  my  knowledge  extends,  only  two  cases  of  such  limited  cellu- 
litis substantiated  by  autopsic  evidence,  one  reported  by  M.  Demarquay,2 
the  other  by  M.  Simon.3  Nevertheless,  judging  from  clinical  observation, 
one  is  inclined  to  side  with  the  view  of  Nonat  rather  than  with  that  of 
Bernutz.  There  are  many  cases  in  which  abscesses  in  the  broad  liga- 
ments point  and  discharge  anteriorly  or  posteriorly  to  the  cervix,  but 
these  come  within  a  different  category.  The  broad  ligaments  and  their 
entire  contents,  cellular  tissue,  ovaries,  and  Fallopian  tubes,  are  more  fre- 
quently affected  than  any  other  parts,  and  M.  Aran  goes  so  far  as  to  say 
that  the  collections  of  pus  occurring  in  periuterine  cellulitis  "  belong  more 
particularly  to  the  ovaries  and  tubes."  In  post-mortem  examinations 
these  parts  are  often  found  imbedded  in  a  mass  of  effused  material,  the 
ovaries,  one  or  both,  in  a  state  of  suppuration,  and  the  tubes  inflamed  and 
filled  with  pus,  or  constricted  at  both  uterine  and  ovarian  extremities  and 
dilated  by  sero-purulent  material  so  as  to  constitute  tubal  dropsy.  I  have 
examined  the  post-mortem  reports  of  cases  by  a  number  of  authorities 
with  reference  to  this  point,  and,  rejecting  only  those  in  which  the  exami- 
nation was  made  in  too  careless  a  manner  to  allow  of  their  admission,  I 
present  them  in  the  following  table : — 

>  Op.  cit.,  p.  237.  *  Gazette  des  Hdpitaux,  April  17,  1858. 

3  Bull,  de  la  Soc.  Axrat.  de  Paris. 


COMPLICATIONS, 


470 


No.  of  Case 

Authority, 

1. 

M. 

Nonat. 

2. 

M. 

Nonat. 

3. 

M. 

Nonat. 

4. 

M. 

Nonat. 

5. 
G. 

Dr.  West. 
Dr.  West. 

7. 
8. 
9. 

Dr.  West. 

Dr.  McClintock 

M.  Demarquay. 

0. 

M.  Simon. 

Scat  of  Purulent  Collection. 

Behind  the  uterus  connecting  with  suppurating 
cyst  in  left  ovary;  small  abscess  in  right 
ovary. 

Behind  uterus  and  rectum  extending  into  broad 
ligaments  of  both  sides. 

On  left  side  extending  from  uterus  to  ilium. 

Behind  uterus  and  vagina  extending  into  left 
broad  ligament ;  another  the  size  of  a  hen's 
egg  just  behind  the  uterus,  opening  into  a 
third,  very  large,  extending  to  sigmoid  flex- 
ure and  into  broad  ligament. 

Left  broad  ligament. 

Opposite  right  sacro-iliac  synchondrosis  under 
psoas  muscle,  another  to  the  left  of  and  behind 
the  rectum. 

Left  broad  ligament. 

Left  broad  ligament. 

In  cellular  tissue  between  uterus  and  rectum 
and  also  in  recto-uterine  pouch  of  peritoneum. 

Size  of  a  small  orange,  between  the  bladder  and 
uterus,  sending  conoidal  prolongation  into  left 
broad  ligament.  Its  limits  were  as  follows : 
base  of  bladder  in  front ;  neck  and  body  of 
uterus  behind  ;  peritoneum  above ;  vagina 
below  ;  at  the  sides  it  ran  off  into  the  broad 
ligaments. 

Left  broad  ligament. 

Left  ovary,  right  tube,  with  pelvic  adhesions 
throughout. 

Size  of  an  apple  in  left  broad  ligament. 

At  side  of  uterus  and  in  the  left  broad  ligament. 

It  will  thus  be  seen  that  of  this  number,  which  is  large  when  it  is  re- 
membered that  the  disease  rarely  ends  in  death,  but  two  cases  present 
instances  of  cellulitis,  uncomplicated  by  disease  of  the  cellular  tissue  of 
the  broad  ligaments,  ovaries,  or  tubes.  One  of  these,  that  of  Simon,  is 
conclusive  of  the  possibility  of  such  disease  ;  that  of  Demarquay  is  doubt- 
ful, for  with  the  abscess  in  the  cellular  tissue,  there  was  also  one  in  the 
cul-de-sac  of  Douglas.  The  purulent  collections  in  this  disease  may  be 
results  of  morbid  action  in  the  cellular  tissue,  the  ovaries,  or  the  Fallopian 
tubes.  In  other  words,  with  the  disease  known  as  cellulitis  we  often, 
indeed  generally,  have  other  affections,  some  of  them,  in  the  present  state 
of  our  knowledge,  not  separable  from  it,  which  attend  upon  it  as  compli- 
cations. 

Complications. — The  complications  of  periuterine  cellulitis  are — 

Pelvic  peritonitis ; 

Ovaritis; 


11. 

M. 

Aran. 

12. 

M. 

Aran. 

13. 

M. 

Bourdon 

14. 

H. 

Aran. 

480  PERIUTERINE    CELLULITIS. 

Fallopian  salpingitis;1 
Endometritis; 
Uterine  displacement. 

The  occurrence  of  these  complications  with  cellulitis  is  so  frequent  that 
they  may,  at  least  the  first  three,  almost  be  regarded  as  elements  of  it, 
when  it  exists  in  severity.  They  are,  indeed,  universally  present  where 
the  tissue  of  the  broad  ligaments  is  seriously  involved,  as  will  be  seen  by 
reference  to  autopsic  evidence  contained  in  any  of  the  works  upon  the 
subject.  The  fact  of  the  frequent  coexistence  of  endometritis  should  be 
especially  noted,  for  great  injury  may  be  done  by  local  treatment  of  it, 
under  the  supposition  that  it  is  the  cause  of  symptoms  which  in  reality 
are  the  results  of  cellulitis. 

Course,  Duration,  and  Termination It   is   necessary  that  I   should 

here  inform  the  reader  that  the  account  which  I  shall  give  of  this  part  of 
our  subject  will  differ  essentially  from  that  generally  found  in  systematic 
works,  for  the  reason  that,  regarding  pelvic  cellulitis  and  pelvic  peritonitis, 
which  are  usually  treated  of  synonymously,  as  different  affections,  I  shall 
attempt  to  describe  them  separately.  Cellulitis  proper,  that  is,  uncompli- 
cated by  other  diseases,  rarely  passes  into  a  chronic  state,  but  usually  in 
the  course  of  two  or  three  weeks  passes  off  by  resolution  or  ends  in  suppu- 
ration, the  former  being  much  the  more  frequent  termination.  Any  one 
of  its  usual  complications,  however — peritonitis,  endometritis,  ovaritis,  or 
salpingitis — may  become  chronic,  and  thus  leave  the  impression  upon  the 
mind  of  the  observer  that  the  original  affection  has  done  so.  Or  one  or 
more  abscesses  may  discharge  themselves  by  long  sinuses  which  fail  to 
allow  of  their  complete  evacuation,  and  may  continue  to  pour  out  pus  for 
months  or  even  years.  In  saying  that  cellulitis  rarely  becomes  chronic,  I 
look  upon  chronic  pelvic  abscess  rather  as  one  of  its  results  than  one  of  its 
stages.  If  the  case  be  of  acute  character  and  occur  as  a  sequel  of  partu- 
rition, suppuration  may  take  place  in  a  few  days,  but  ordinarily,  even 
under  these  circumstances,  it  does  not  occur  for  two  or  three  weeks.  In 
a  chronic  case  the  effused  matter  may  remain  hard,  resisting,  and  ligneous 
for  months  without  showing  signs  of  softening,  but  such  instances  are  ex- 
ceptions to  the  rule.  After  suppuration  has  occurred  the  disease  may 
follow  one  of  three  courses  : — 

1st.  The  accumulated  pus  may  discharge  itself  and  the  abscess  gradu- 
ally dry  up  and  disappear. 

2d.  The  empty  sac,  lined  by  pyogenic  membrane,  may  for  an  unlimited 
time  go  on  pouring  out  pus. 

3d.  Small  abscesses  may  form  and  discharge  in  one  part,  then  others 
may  do  so  in  another,  until  the  whole  pelvic  areolar  tissue  is  perforated 
by  them  and  by  fistulous  tracts  connecting  them. 

1  oa\m\.y%,  "  a  tube." 


PROGNOSIS — CAUSES.  481 

There  are  various  outlets  for  the  imprisoned  purulent  accumulation  : — 

1st.   Through  the  abdominal  walls  or  saphenous  openings  ; 

2d.  Through  the  pelvic  viscera,  bladder,  rectum,  vagina,  urethra,  or 
uterus ; 

3d.    Through  the  floor  of  the  pelvis  near  the  anus  ; 

4th.  Through  the  pelvic  foramina,  obturator,  or  sacro-ischiatic  ; 

5th.  Through  the  pelvic  roof  into  the  peritoneal  cavity. 

Sometimes  the  purulent  collection  burrows  into  the  surrounding  tissues 
and  evacuates  itself  at  a  distance.  In  one  case  which  I  saw  with  Dr. 
Echeverria,  it  passed  through  the  sciatic  foramen,  and,  burrowing  upwards 
and  forwards,  came  forth  near  the  great  trochanter.  It  may  thus  take  so 
eccentric  a  course  as  to  mislead  the  practitioner  as  to  the  seat  of  the 
abscess. 

The  most  frequent  channels  of  evacuation  are  the  vagina  and  rectum, 
in  the  non-puerperal  form,  and  probably  the  abdominal  walls  in  the  puer- 
peral, or  at  least  the  results  of  Dr.  McClintock's1  carefully  noted  cases 
would  lead  us  to  believe  so.  In  37  puerperal  cases  treated  by  him  which 
ended  in  suppuration,  20  abscesses  discharged  in  the  iliac  regions,  2  above 
the  pubes,  1  in  the  inguinal  region,  and  1  beside  the  anus.  Of  the 
remaining  13,  6  were  discharged  per  vaginam,  5  per  anum,  and  2  burst 
into  the  bladder.  In  the  non-puerperal  variety  it  is  extremely  rare  for 
the  abscess  to  discharge  externally,  and  fortunately  in  both  forms  it  is 
rare  for  it  to  burst  into  the  perineum. 

Prognosis. — A  guarded  prognosis  should  always  be  made  as  to  the  time 
of  recovery,  for  no  amount  of  experience  can  foresee  the  course  of  the 
affection ;  whether  the  effused  liquor  sanguinis  will  disappear  by  absorp- 
tion in  three  weeks ;  whether  the  discharge  of  one  abscess  will  end  the 
patient's  suffering  ;  or  whether  a  chronic  induration  will  exist  for  a  great 
length  of  time.  But  fortunately  it  may  be  stated,  that  the  prospects  as  to 
life  are  decidedly  favorable,  though  in  cases  occurring  just  after  parturi- 
tion, there  is  always  some  danger  from  general  peritonitis. 

Causes The  disease  usually  occurs  as  a  result  of  one  of  the  following 

causes  : — 

Parturition  or  abortion ; 

Inflammation  of  uterus  or  ovaries  ; 

Direct  injury  from  coition,  caustics,  pessaries,  operations,  or  blows. 

Parturition  or  abortion  produces,  according  to  statistics,  from  one-half 
to  two-thirds  of  all  the  cases.  Even  this  large  proportion  I  believe  to  fall 
short  of  the  truth,  from  the  fact  that  those  collecting  the  statistics  from 
which  the  deductions  were  drawn  made  no  distinction  between  this  disease 
and  pelvic  peritonitis.  Cellulitis  will  very  rarely  be  met  with,  except 
after  the  parturient  process.     It  is  true  that,  when  the  puerperal  state 

1  Op.  cit. 
31 


482  PERIUTERINE    CELLULITIS. 

exists  as  a  predisposing  cause,  exposure  to  cold,  fatigue,  over-exertion, 
etc.,  will  excite  it ;  but  under  these  circumstances  they  are  merely  imme- 
diate and  exciting  influences. 

Inflammation  of  the  Ovaries  or  Uterus.  It  is  rare  to  meet  with  the 
affection  in  a  non-puerperal  patient,  as  the  result  of  exposure,  unless  she 
be  suffering  from  disease  of  these  organs.  Aran  believes  disease  in  the 
ovaries  to  be  "  almost  always  the  cause."  It  is  certain  that  these  organs 
are  generally  diseased  where  the  affection  exists,  but  it  is  difficult  to  de- 
termine whether  as  a  complication,  or  as  the  first  link  in  the  chain.  In 
the  histories  of  fourteen  autopsies  which  I  have  collected,  the  state  of  the 
ovaries  is  mentioned  in  ten.  Out  of  these  they  were  affected  by  inflam- 
mation in  seven.  In  some  of  the  seven  cases,  abscesses  existed  ;  in  others 
their  tissue  was  in  part  destroyed,  and  in  others  they  had  entirely  disap- 
peared. Any  chronic  or  acute  disease  of  either  the  uterine  parenchyma 
or  mucous  lining,  may  also  result  in  it,  and  I  have  more  than  once  seen 
it  follow  applications  of  mild  character  to  the  cavity  of  the  uterus. 

Direct  injury  is  by  no  means  a  rare  cause  in  non-puerperal  cases,  though 
it  generally  proves  active  in  those  suffering  from  previous  uterine  or  ovarian 
disorders.  Thus  it  may  follow  operations  upon  the  neck  or  body  of  the 
uterus,  slitting  the  neck  for  flexion  or  contraction,  for  example,  or  simple 
dilatation  by  a  tent.  It  may  result  from  efforts  at  removal  of  intra-uterine 
growths,  and  one  fatal  case  that  I  have  met  followed  the  ligation  of  haemor- 
rhoids. 

The  important  fact,  that  this  disease  is  usually  not  an  idiopathic  affec- 
tion, but  one  symptomatic  of  uterine  or  ovarian  inflammation,  has  been 
especially  insisted  on  by  Dr.  Matthews  Duncan,  who  first  drew  attention 
to  it  as  early  as  1853. 

Symptoms. — The  acute  form,  and  nlore  especially  that  occurring  after 
parturition,  is  usually  ushered  in  by  very  decided  symptoms,  of  which  the 
most  constant  are  the  following  : — 

Chill ; 

Increased  thermometric  range ; 

Pain  ; 

Fever ; 

Dysuria  ; 

Metrorrhagia. 
The  chill,  though  sometimes  absent,  is  a  very  general  symptom.  No 
sooner  does  it  pass  off  than  the  pulse  rises  to  110  or  120,  increased  heat 
is  felt  in  the  hypogastric  region,  and  pain,  which  for  a  number  of  hours 
or  perhaps  days  before  was  just  perceptible,  comes  on  with  considerable 
violence.  The  thermometer  shows  marked  increase  of  animal  heat,  the 
mercury  rising  to  103°  or  104°,  and,  in  severe  cases,  even  higher.  With 
these  general  symptoms  there  will  be  others  pointing  to  the  rectum  and 
bladder,  and  should  the  affection  exist  in  a  menstruating  woman  the  flow 


PHYSICAL    SIGNS.  |S:5 

may  be  much  increased.  Even  when  the  patient  is  not  menstruatiii", 
uterine  hemorrhage  sometimes,  though  not  frequently,  comes  on. 

But  he  who  awaits  these  symptoms  for  diagnosis  will  be  led  into  many 
errors  of  omission,  for  subacute  cases  very  generally,  and  acute  cases 
sometimes,  fully  develop  themselves  without  them. 

All  cases  may  be  brought  under  three  heads  as  to  severity  of  symp- 
toms : — 

1st.  Cases  accompanied  by  chill,  fever,  pain,  and  ordinary  signs  of 
inflammation  ; 

2d.  Those  accompanied  by  pain  without  chill  or  fever; 

3d.  Those  marked  by  scarcely  any  symptoms  except  extreme  feeble- 
ness and  some  sense  of  pulsation  and  weight  about  the  pelvis,  with  hectic 
fever  towards  evening. 

Cases  which  have  assumed  the  chronic  form  will  present  themselves 
with  such  a  history  as  this  :  a  patient  who  was  delivered  one,  two,  or 
three  months  ago  has  not  recovered  her  strength,  but  is  very  feeble,  has 
no  appetite,  and  feels  nervous,  depressed,  and  feverish  towards  evening. 
She  has  no  absolute  pains,  but  fears  that  something  is  wrong  about  the 
womb,  for  now  and  then  she  feels  a  sensation  of  throbbing,  tension,  and 
weight  about  that  organ,  which  is  increased  by  defecation,  urination,  and 
walking.  This  prompts  to  physical  exploration,  which  establishes  the 
diagnosis. 

Physical  Signs Physical  exploration  is  the  means  on  which  we  must 

rely  for  a  rapid  and  certain  determination  of  the  character  of  these  cases. 
Should  the  finger  be  introduced  into  the  vagina  during  the  first  stage,  the 
parts  will  be  found  to  be  very  warm,  and  perhaps  a  swollen  and  oedema- 
tous  spot  may  be  detected.  Upon  pressing  in  different  directions  great 
sensitiveness  will  be  observed,  and  by  conjoined  manipulation  a  particu- 
larly sensitive  point  will  be  detected,  usually  on  one  side  of  the  uterus. 

As  the  second  stage,  or  stage  of  effusion,  advances,  induration  occurs  in 
the  areolar  tissue  affected,  and  then,  by  careful  vaginal  touch  combined 
wTitli  external  manipulation,  a  tumor  as  large  as  a  walnut,  a  goose's  egg, 
or  an  orange,  may  be  detected  in  one  of  the  broad  ligaments,  or  in  the 
tissue  around  the  cervix. 

But  the  examiner  must  not  suppose  that  the  mere  introduction  of  the 
finger  into  the  vagina  will  accomplish  a  discovery  which  often  requires 
the  greatest  care  and  most  thoughtful  attention  in  examination.  The 
finger  being  passed  up  to  the  cervix,  and  the  other  hand  placed  upon  the 
hypogastrium  so  as  to  make  counter-pressure,  it  should  be  carefully  pressed 
against  Douglas's  cul-de-sac  and  all  around  the  cervix  over  the  base  of  the 
bladder  and  as  far  as  possible  towards  the  fundus.  Then  it  should  be 
made  in  a  similarly  careful  manner  to  traverse  the  sides  of  the  pelvis 
where  tne  broad  ligaments  are  placed,  and  last  of  all,  those  parts  below 
the  pelvic  roof.     For  one  sufficiently  practised  in  this  kind  of  examination 


484  PERIUTERINE    CELLULITIS. 

this  procedure  will  generally  be  sufficient  to  determine  the  existence  of 
even  a  very  small  point  of  induration  on  the  sides  or  in  front  of  the  uterus. 
Sometimes,  where  it  is  posterior  to  that  organ,  a  rectal  exploration  will 
throw  much  additional  light  upon  the  case. 

Should  the  disease  have  advanced  to  its  third  stage,  in  addition  to  the 
signs  already  noted,  the  uterus,  which,  as  already  mentioned,  is  generally 
displaced,  is  now  pushed  from  its  normal  position,  in  a  direction  opposite 
to  the  accumulated  pus.  Sometimes  it  lies  upon  the  floor  of  the  pelvis,  at 
others  it  is  in  a  state  of  anteversion,  retroversion,  or  lateroversion,  and, 
more  rarely,  sharply  flexed,  the  body  having  remained  movable  after  the 
cervix  has  become  fixed. 

Into  whatever  malposition  it  has  been  forced  it  remains  to  a  certain 
extent  immovable,  from  fixation  by  adhesive  lymph.  But  this  fixation  is 
by  no  means  so  complete,  so  universal,  as  in  pelvic  peritonitis.  I  feel 
satisfied  that  I  have  seen  two  unquestionable  cases  in  which  no  fixation  of 
the  uterus  existed  at  all.  This,  however,  is  very  rare.  Nonat  has  even 
gone  so  far  as  to  declare  that  the  phlegmonous  mass  itself  may  be  movable, 
and  Dr.  Duncan  reports  one  case  which  appears  to  verify  this  statement; N 
I  have  never  seen  an  instance  in  which  this  mass  was  not  firmly  fixed. 

Differentiation — The  diseases  with  which  it  may  be  confounded  are — 
Fibrous  tumors; 
Hematocele ; 
Pelvic  peritonitis  ; 
Early  pregnancy. 

Fibrous  tumors  are  painless,  free  from  tenderness,  and  movable  in  the 
pelvis.  They  are  unaccompanied  by  chill,  fever,  and  other  signs  of 
inflammation,  and  are  closely  attached  to  the  uterus,  so  as  to  form  part  of 
it.  The  tumors  resulting  from  cellulitis  are  the  contrary  of  all  this,  and 
appear  firmly  attached,  like  bony  growths,  to  the  walls  of  the  pelvis. 

Hematocele  occurs  suddenly  with  uterine  hemorrhage,  and  is  marked 
by  prostration,  coldness,  and  other  symptoms  of  loss  of  blood.  The  tumor 
created  is  soft  in  the  beginning  and  grows  hard;  that  of  cellulitis  is  hard 
in  the  beginning  and  tends  to  softening. 

Pelvic  peritonitis  shows  the  ordinary  signs  of  peritoneal  inflammation, 
great  tendency  to  relapse  at  menstrual  periods,  excessive  pain  and  tender- 
ness, and  produces  no  distinct  tumor  in  the  beginning,  but  hardening  of 
the  whole  pelvic  roof.  Later,  a  small  tumor  may  be  discovered,  but  it  is 
usually  posterior  to  the  uterus  and  not  on  one  side  of  it.  The  uterus  is 
less  movable  than  in  cellulitis,  and  when  the  body  is  fixed  the  cervix 
sometimes  moves  under  pressure. 

Dr.  Geo.  Engelman1  has  drawn  attention  to  a  rare  class  of  cases  in 
which  early  pregnancy  simulates  this  disorder  very  closely. 

1  St.  Louis  Med.  and  Surg.  Journal. 


TREATMENT.  485 

Consequences  of  Cellulitis. — The  remote  results  of  this  affection  are  so 
grave,  that  even  if  there  were  no  dangers  immediately  connected  with  it, 
they  would  stamp  its  occurrence  as  a  great  disaster.  The  ovaries  are  at 
times  destroyed  hy  suppurative  action;  at  others  they  undergo  an  atrophy, 
the  result  of  inflammation,  and  the  Fallopian  tubes  are  often  left  imper- 
vious. The  uterus  is  often  permanently  displaced  in  consequence  of 
strong  adhesions  which  bind  it  in  a  bad  position.  From  this  results  the 
fact  that,  although  the  disease  be  cured,  the  patient  is  often  left  incapaci- 
cated  for  some  of  the  most  important  physiological  functions.  Sterility, 
amenorrhoea,  dysmenorrhea,  monorrhagia,  tubal  dropsy,1  and  displace- 
ment may  remain  to  attest  the  gravity  of  the  original  disease,  and  continue 
for  an  unlimited  time  a  source  of  suffering  for  the  patient  and  discourage- 
ment for  the  physician. 

Treatment Should  the  practitioner  be  called  in  the  acute  stage  of  cel- 
lulitis, the  patient  should  be  at  once  completely  quieted  by  opium.  If 
pain  be  violent,  the  hypodermic  method  should  be  employed  in  its  admin- 
istration; if  not,  it  should  be  given  by  mouth  or  rectum.  This  drug 
throughout  the  acute  stage  of  the  affection  should  be  steadily  kept  up.  It 
accomplishes  these  results:  it  relieves  pain,  diminishes  the  severity  of  the 
inflammatory  process,  keeps  the  bowels  constipated,  produces  sleep,  and 
creates  general  nervous  quietude.  If  when  first  seen  the  patient  be  suffer- 
ing very  severely,  ten  drops  of  Magendie's  solution  of  morphia  may  be 
injected  by  the  hypodermic  syringe  into  the  cellular  tissue  of  the  arm. 

Absolute  rest  should  be  enjoined,  the  patient  not  being  allowed  to  sit 
up  in  bed  for  a  moment,  upon  any  pretext  whatever.  Were  I  limited  to 
one  remedial  resource  in  this  affection,  I  should  choose  rest  in  preference 
to  all  others,  but  to  accomplish  anything  it  must  be  absolutely  enforced. 

The  diet  of  the  patient  should  be  mild  and  unstimulating,  consisting  of 
milk  with  farinaceous  substances,  and  tea  or  coffee. 

If  the  case  be  seen  very  early,  before  the  stage  of  effusion  has  occurred, 
a  bladder  of  crushed  ice  should  be  laid  over  the  hypogastrium  in  the  hope 
of  arresting  the  advance  of  the  disease.  But  if  the  disease  has  advanced 
beyond  the  point  where  this  seems  possible,  warm  poultices  of  powdered 
linseed  should  be  applied  every  third  or  fourth  hour  over  the  hypogastrium, 
the  bowels  be  kept  constipated,  and  febrile  action,  should  it  exist,  be  quieted 
by  refrigerants  and  direct  sedatives,  as  tincture  of  veratrum  viride,  tinc- 
ture of  aconite,  or  tincture  of  gelseminum. 

As  soon  as  the  acute  symptoms  have  passed,  and  vaginal  touch  informs 
us  that  the  effused  material  is  becoming  thoroughly  organized,  a  further 
effort  should  be  made  to  break  up  the  morbid  train  before  it  passes  on  to 
suppuration  or  into  chronic  induration,  by  the  application  of  a  blister,  six 
by  eight  inches,  over  the  hypogastrium.     This  should  not  be  applied  be- 

1  Aran,  op.  cit.,  p.  638. 


486  PERIUTERINE    CELLULITIS. 

fore  febrile  action  and  the  most  acute  symptoms  have  disappeared.  Some 
excellent  authorities,  among  others  Sir  James  Simpson,  object  to  blistering 
for  fear  of  strangury  resulting.  I  have  never  had  to  do  otherwise  than 
congratulate  myself  on  its  employment.  Should  the  case  tend  to  an  acute 
course,  and  suppuration  be  impending,  this  should  be  encouraged  by  con- 
stant poulticing. 

As  soon  as  the  acuteness  of  the  attack  has  passed,  until  which  time 
attention  should  be  turned  to  quieting  the  general  symptoms  of  inflamma- 
tion, it  is  advised  by  the  best  authorities  that  the  iodide  or  bromide  of 
potassium  should  be  administered,  the  former  in  five-grain  doses  repeated 
every  third  or  fourth  hour,  or  the  latter  in  doses  of  ten,  fifteen,  or  even 
twenty  grains,  at  the  same  intervals.  At  the  same  time  that  I  am  not 
prepared  to  deny  the  utility  of  these  drugs,  I  confess  that  I  have  never 
been  able  to  persuade  myself  that  they  really  accomplish  any  good  result. 

There  is  no  more  certain  method  of  disgorging  the  veins  of  the  pelvis 
and  lower  bowel  than  by  acting  upon  the  liver,  which  governs  the  outlet 
of  the  portal  system,  with  which  they  are  connected,  and  this  can  most 
readily  be  done  by  mercurial  cathartics.  Thus  occasionally  used,  the 
mercurials  prove  of  great  benefit  in  relieving  congestion,  which  is  a  lead- 
ing element  of  the  disease.  But  in  doing  this  we  are  not  developing  the 
specific  action  of  these  medicines,  which  here  act  as  a  subordinate,  and 
not  the  chief  element  of  treatment.  The  production  of  ptyalism  should 
be  avoided,  since  it  is  by  no  means  certain  that  it  is  of  any  benefit,  and 
by  impoverishing  the  blood  at  the  commencement  of  what  may  become  an 
exhausting  disease  it  may  do  absolute  injury.  As  the  acuteness  of  the 
affection  subsides  the  bowels  should  be  kept  free  by  laxative  medicines, 
and  the  occasional  use  of  a  mercurial  in  this  capacity  is  indicated.  It 
may  be  necessary  to  repeat  the  application  of  the  blister  before  the  case 
ends  in  suppuration  or  passes  into  the  chronic  stage. 

While  the  patient  remains  in  bed,  warm  poultices,  or  towels  wrung  out 
of  warm  water  and  covered  by  oil  silk,  should  be  worn  over  the  hypogas- 
trium.  An  additional  emollient  remedy  of  great  value  is  the  persevering 
use  of  the  warm  douche  for  fifteen  or  twenty  minutes,  night  and  morning, 
after  Emmet's  method,  already  described.  The  fluid  used  should  be  as 
warm  as  the  patient  can  bear  it,  and  may  be  slightly  medicated  in  the 
later  stages  by  the  addition  of  chloride  of  sodium,  tincture  of  iodine,  or 
iodide  of  potassium.  The  injections  stimulate  the  absorbents,  and,  at  the 
same  time,  quiet  inflammatory  action,  in  the  performance  of  which  func- 
tions they  are  invaluable  in  these  cases. 

As  the  third  stage  of  the  disease,  or  the  stage  of  suppuration,  merges 
into  pelvic  abscess,  it  will  be  best  to  postpone  the  consideration  of  its 
management  to  the  chapter  in  which  that  subject  is  treated.  I  will  merely 
state  here  that  after  an  abscess  has  formed  and  evacuated  itself,  great  care 


PELVIC    PERITONITIS.  487 

should  be  taken  not  to  allow  the  patient  to  exert  herself  for  several  weeks, 
for  fear  of  a  relapse,  and  even  after  she  has  left  the  house  and  begun  to 
exercise  regularly,  during  two  or  three  menstrual  periods  she  should  con- 
fine herself  to  bed. 


CHAPTER  XXXI. 

PELVIC  PERITONITIS. 

Definition Inflammation  involving  the  peritoneum  covering  the  female 

pelvic  viscera,  and  limited  to  it,  receives  the  name  of  pelvic  peritonitis. 
It  must  not  be  supposed  that  by  this  definition  is  meant  simply  that  form 
of  peritoneal  inflammation  arising  in  the  pelvis  and  spreading  into  general 
peritonitis,  which  has  long  been  described  as  metro-peritonitis.  The 
disease  that  we  are  now  considering  is  one  usually  strictly  limited  to  the 
pelvis,  presenting  symptoms  peculiar  to  itself,  and  rarely  passing  into  the 
general  form  of  the  same  disorder. 

History. — Long  before  pelvic  cellulitis  was  known,  peritonitis,  limited 
to  the  serous  covering  of  the  pelvic  organs,  had  attracted  attention,  and 
its  clinical  resemblance  to  cellulitis,  as  subsequently  described,  fully  noted. 
Thus  Morgagni1  relates  a  case  in  which,  thirty  days  after  delivery,  the 
right  ovary  and  tube  were  adherent  to  the  colon  and  almost  destroyed  by 
an  abscess.  Nauche,  in  his  work  on  Diseases  of  the  Uterus,  published  at 
Paris  in  1816,  described  inflammation  of  the  uterus  as  affecting,  first,  the 
mucous  membrane  ;  second,  the  parenchyma ;  and,  third,  the  serous  cover- 
ing. In  1828,  Mad.  Boivin  credited  the  adhesions  resulting  from  this 
affection  and  binding  the  uterus  down  with  a  large  number  of  abortions 
attributed  to  other  causes ;  and,  in  1833,  she  described  immobility  of  the 
uterus,  for  which  she  gave  as  causes,  peritonitis,  metro-peritonitis,  and 
pelvic  abscess.  In  1839,  Grisolle2  distinctly  stated,  that  "  there  are  cases 
of  circumscribed  peritonitis  which,  producing  a  tumor  appreciable  to  sight 
and  to  touch,  may  lead  to  the  belief  in  the  existence  of  phlegmon,"  i.  e., 
a  tumor  the  result  of  inflammation  of  areolar  tissue.  Lisfranc,3  writing 
ten  years  after  Boivin  and  Duges,  copies  their  description  very  closely  in 
his  article  on  "  Fixite  de  la  Matrice,"  without  referring  to  them,  and  like 
them  attributes  it  to  peritonitis  or  metro-peritonitis. 

Although    these    facts    were    known    and    universally   admitted,    they 

1  Artie.  22,  epist.  46.     Nonat,  op.  cit.,  p.  234. 

2  Bernutz  and  Goupil,  op.  cit.,  p.  398. 
8  Clin.  Med.,  vol.  iii.  p.  514. 


488  PELVIC    PERITONITIS. 

attracted  little  notice,  and  after  the  description  of  pelvic  cellulitis  by 
Doherty  and  Marchal  de  Calvi,  pelvic  peritonitis  was  almost  entirely  lost 
sight  of.  This  was  due  to  the  fact  that  the  enthusiasm  created  by  the 
description  of  a  long-forgotten  affection  caused  observers  to  look  upon  the 
results  of  peritonitis  as  those  of  cellulitis,  and  to  describe  them  as  such. 
Thus  the  matter  rested  until  1857,  when  M.  Bernutz,  in  a  treatise  written 
in  concert  with  M.  Goupil,  not  only  drew  especial  notice  to  it,  but  took 
the  position  that  inflammation  of  the  cellular  tissue  immediately  around 
the  uterus,  descrihed  by  Nonat  as  "  phlegmon  periuterin,"  or  what  would 
strictly  be  termed,  in  our  nomenclature,  "  periuterine  cellulitis,"  did  not 
exist  as  a  pathological  reality,  but  that  the  lesions  ascribed  to  it  were 
absolutely  due  to  pelvic  peritonitis. 

These  views,  published  at  first  in  the  "  Archiv.  Gen.  de  Med.,"1  are 
fully  elaborated  in  the  admirable  work2  of  these  observers  more  recently 
brought  forth.  They  do  not  touch  the  general  subject  of  periuterine  cellu- 
litis as  it  exists  in  the  broad  ligaments,  subperitoneal  tissue,  and  around 
the  rectum,  but  only  that  variety  supposed  to  have  its  seat  in  the  areolar 
tissue  between  the  uterus  and  peritoneum. 

It  has  been  already  stated  that  M.  Bernutz  was  incited  to  his  investi- 
gations by  certain  views  advanced  by  M.  Nonat  as  to  the  pathology  of 
periuterine  induration,  which  sometimes  goes  on  to  suppuration.  But 
his  researches  served  not  merely  to  settle  this  comparatively  unimportant 
point,  they  proved  the  fact,  for  which  the  investigator  appears  to  have 
been  himself  entirely  unprepared  in  the  beginning,  that  many  of  those 
cases  regarded  as  instances  of  non-puerperal  cellulitis  are  in  reality  not 
phlegmonous  but  peritoneal  inflammations.  Since  the  publication  of  these 
views  I  have  directed  my  attention  particularly  to  this  point,  and  from 
careful  observation,  both  clinical  and  post-mortem,  feel  warranted  in 
recording  the  conclusions  at  which  I  have  arrived  in  the  following  propo- 
sitions : — 

1st.  Periuterine  cellulitis  is  rare  in  the  non-parous  woman,  while  pelvic 
peritonitis  is  exceedingly  common; 

2d.  A  very  large  proportion  of  the  cases  now  regarded  as  instances  of 
cellulitis  are  really  those  of  pelvic  peritonitis ; 

3d.  The  two  affections  are  entirely  distinct  from  each  other,  and  should 
not  be  confounded  simply  because  they  often  complicate  each  other.  They 
may  be  compared  to  serous  and  parenchymatous  inflammation  of  the  lungs, 
— pleurisy  and  pneumonia.  Like  them  they  are  separate  and  distinct, 
like  them  affect  different  kinds  of  structure,  and  like  them  generally  com- 
plicate each  other. 

4th.  They  may  usually  be  differentiated  from  each  other,  and  a  neglect 

1  Archiv.  G6n.,  1857.  £  Clin.  M&l.  des  Femmes,  1862. 


HISTORY.  489 

of  the  effort  at  such  thorough  diagnosis  is  as  reprehensible  as  a  similar 
want  of  care  in  determining  between  pericarditis  and  endocarditis. 

M.  Bernutz  cites  the  results  of  five  autopsies1  by  himself,  and  between 
twenty  and  thirty  by  others  which  presented  all  the  signs  of  pelvic  perito- 
nitis and  none  of  cellulitis,  although  during  life  the  symptoms  and  signs 
generally  attributed  to  the  latter  disease  were  present.  As  an  example 
conveying  some  idea  of  the  close  clinical  resemblance  between  his  cases 
found  in  autopsy  to  be  peritonitis  and  those  ordinarily  regarded  as  cellulitis, 
I  quote  the  salient  points  in  his  sixth  observation. 

Patient  33,  lymphatic  temperament,  entered  hospital  November  24th 
for  feebleness,  pain  in  the  back,  emaciation,  and  dysmenorrhea.  After  a 
while  loss  of  appetite,  increase  of  pain,  and  chills  appeared.  By  touch  the 
uterus  was  found  completely  fixed,  low  down  in  the  pelvis  and  inclined  to 
the  right  side,  and  attached  to  it  a  very  sensitive  tumor  the  size  of  a  hen's 
egg,  extending  behind  the  womb.  On  the  loth  of  December  this  tumor 
was  as  large  as  a  turkey's  egg.  February  1st:  tumor  only  the  size  of  a 
pigeon's  egg  ;  a  circumscribed  tumor  on  the  left  attached  to  uterus  and  to 
the  walls  of  the  pelvis.  March  23d,  uterus  movable  and  tumor  reduced 
to  the  size  of  a  little  nut.  April  4th,  she  died ;  and  autopsy  showed 
tubercular  pelvic  peritonitis,  evidenced  by  tubercular  deposit,  lymph,  pus, 
firm  old  adhesions,  ovaries  imbedded  in  false  membrane  and  nearly  de- 
stroyed. 

I  had  often  been  struck  by  the  great  similarity  between  peritonitis  and 
many  of  the  cases  of  what,  until  enlightened  by  M.  Bernutz,  I  had  re- 
garded as  cellulitis,  and  by  the  fact  that  they  occasionally  ran  into  general 
peritonitis  without  any  apparent  emptying  of  purulent  collections  into  the 
peritoneal  sac,  but  I  never  had  an  opportunity  of  examining  such  a  case 
post  mortem  until  the  following  presented  itself: — 

Mrs.  M.,  aged  35,  married,  but  never  pregnant,  had  been  under  my  care, 
during  the  winter,  at  the  Woman's  Hospital,  for  anteflexion  of  the  uterus, 
the  result,  as  I  supposed,  of  periuterine  cellulitis.  August  6th,  I  was 
called  to  see  her  in  consultation  with  Dr.  Roth,  her  family  physician,  and 
found  her  suffering  from  severe  pelvic  pain,  constant  vomiting,  and  fever. 
Upon  vaginal  touch  I  found  the  uterus  immovably  fixed  and  the  pelvic 
roof  as  hard  as  a  board.  The  pelvic  tissue  was  everywhere  hard  and 
resisting,  and  the  physical  signs  of  what  I  had  habitually  styled  cellulitis 
were  present.  About  a  week  afterwards  the  patient  died  suddenly  and 
unexpectedly,  and  I  made  an  autopsy  in  presence  of  Drs.  Roth  and  J.  C. 
Smith.  No  general  peritonitis  existed  ;  the  left  ovary  presented  a  sac  the 
size  of  a  hen's  egg,  filled  with  pus  ;  the  pelvic  peritoneum  was  intensely 
inflamed   and   the  uterus  bound    down  by  old  false   membranes,  bands  of 

1  I  have  rejected  a  number  of  the  cases  reported,  because  not  sufficiently  con- 
clusive. 


490 


PELVIC    PERITONITIS. 


which  matted  all  the  parts  together.  The  vermiform  appendage  was  bound 
to  the  right  ovary  and  the  caput  coli  lay  just  below  the  uterus.  No  trace 
of  inflammation  could  be  discovered  in  the  pelvic  cellular  tissue  except,  of 
course,  that  in  immediate  contact  with  the  ovary. 

The  fixation  of  the  uterus,  observed  during  life,  was  due  to  lymph  effused 
upon  the  pelvic  peritoneum,  and  no  trace  of  inflammatory  action  in  the 
pelvic  areolar  tissue  could  be  discovered  as  accounting  for  it.  It  is  true 
that  the  left  ovary,  enveloped  by  the  layers  of  the  broad  ligament,  was 
inflamed,  and  that  a  certain  amount  of  inflammation  existed  in  the  cellu- 
lar tissue  immediately  surrounding  it,  but  this  did  not  extend. 

Frequency A  reference  to  the  autopsic  notes  of  cases  of  cellulitis,  for 

example  those  recorded  by  West,  Nonat,  Aran,  and  McClintock,  will  give 
abundant  evidence  of  the  almost  universal  attendance  of  this  complication 
upon  it.  But,  even  without  the  existence  of  that  disease,  Aran  found  it 
in  greater  or  less  degree  in  fifty-five  per  cent,  of  cadavers  of  women  ex- 
amined in  his  service.  This  proves  that  peritonitis,  limited  to  the  pelvic 
viscera,  is  a  common  affection,  and  one  which  is  very  generally  overlooked. 
It  is  probably  to  its  occurrence  that  are  due  so  many  of  those  attacks  of 
violent  hypogastric  pain  occurring  with  menstruation,  or  just  after  it, 
accompanied  by  vomiting  and  slight  febrile  action,  and  which  are  generally 
treated  by  domestic  remedies  and  viewed  as  cramps  or  uterine  colic. 

Pathology — The  disease  runs  its  course  here,  as  peritoneal  inflamma- 
tion does  elsewhere,  in  three  stages.  In  the  first  there  are  simple  engorge- 
ment and  turgescence  of  the  vessels,  producing  redness,  dryness,  and  pain. 

Fig.  208. 


The  straight  line  represents  approximately  the  roof  of  the  pelvis  ; 
the  dotted  line  represents  it  more  exactly. 

In  the  second  stage  an  entirely  different  state  of  things  will  be  found  to 
exist,  to  comprehend  which  fully,  the  reader  must  bear  in  mind  what  is 
meant  by  the  "  roof  of  the  pelvis."    If  a  plane  be  passed  backwards  from 


CAUSES.  491 

a  point  just  under  the  pubic  arch,  through  the  cervix  uteri  at  the  attach- 
ment of  the  vagina,  to  the  sacrum  at  the  attachment  of  the  utero-sacral 
ligaments,  it  will  correctly  represent  this  roof,  which  is  thus  formed  by  the 
vesico-vaginal  septum,  the  lower  extremity  of  the  uterus,  which  projects, 
as  it  were,  through  a  hole  in  the  roof,  the  upper  part  of  the  fornix  vaginae, 
and  the  utero-sacral  ligaments.  Above  the  plane,  the  organs  of  reproduc- 
tion float,  as  Nonat  expresses  it,  "  in  an  atmosphere  of  cellular  tissue." 
Let  the  reader  suppose  that  instead  of  this  yielding,  springy  tissue,  these 
organs  were  fixed  in  their  places  by  having  a  fluid  mixture  of  plaster  of 
Paris  poured  around,  among,  and  over  them,  which  had  afterwards  be- 
come solid,  and  he  may  form  a  correct  idea  of  what  vaginal  exploration 
will  yield  to  the  sense  of  touch  in  the  second  stage.  The  roof  of  the 
pelvis  is  hard,  ligneous,  and  as  if  composed  of  a  "  deal  board,"  to  which 
Prof.  Doherty  likens  it.  The  uterus,  which  is  generally  much  displaced, 
is  immovable,  and  all  its  appendages  appear  fixed  by  some  solid  surround- 
ing element. 

This,  the  second,  stage  consists  in  a  collection  of  plastic  lymph  on  the 
surface  of  the  peritoneum,  and  of  serous,  purulent,  or  sero-purulent  fluid 
in  its  most  dependent  parts. 

In  the  third  stage  the  fluid,  if  serous,  is  absorbed ;   if  purulent,  dis- 
charged, and  the  exuded  lymph  undergoes  organization  and  subsequently 
contraction.     This  binds  the  uterus,  its  appendages,  and  some  of  the  intes- 
tines together  in  a  mass,  which  yields  all  the  physical  signs  of  a  tumor. 
Causes. — Its  causes  are  the  following  : — 

Periuterine  cellulitis ; 

Parturition  or  abortion ; 

Gonorrhoea ; 

Endometritis,  ovaritis,  or  salpingitis  ; 

Escape  of  fluids  into  the  peritoneum  ; 

Traumatic  influences ; 

Imprudence  during  menstruation  ; 

Tuberculous  or  cancerous  deposit ; 

Uterine  displacement. 
Its  frequent  dependence  on  the  first  needs  no  further  mention. 
As  a  result  of  parturition  or  abortion,  it  is  so  well  known  as  to  make 
the  exhibition  of  proof  here  almost  unnecessary.  Reference  may  be  made, 
however,  to  53  autopsies  by  Aran,1  in  which,  out  of  38  women  who  had 
borne  children,  24  presented  evidences  of  its  previous  existence,  while 
out  of  15  who  were  nulliparous,  only  5  did  so. 

Gonorrhoea,  by  passing  into  the  uterus  and  through  the  Fallopian  tubes, 
is  a  fruitful  source  of  the  affection.  According  to  M.  Bernutz,  28  out  of 
99  of  his  cases  had  this  origin.     I  have  seen  a  number  of  severe  cases  due 

»  Op.  cit.,  718. 


492  PELVIC    PERITONITIS. 

to  it,  and  the  great  importance  attached  to  this  cause  by  Noeggerath  is 
elsewhere  fully  stated. 

It  would  be  strange  if  ovaritis  and  endometritis  did  not,  at  times,  cause 
pelvic  peritonitis.  That  they  frequently  do  so,  is  abundantly  demonstrated 
by  autopsies  made  alter  their  existence  both  in  the  puerperal  and  non- 
puerperal states. 

Salpingitis  causes  it  not  only  by  the  extension  of  inflammation  along 
the  mucous,  into  the  serous  membrane  which  is  continuous  with  it,  but 
by  emptying  its  accumulated  pus  into  the  peritoneal  cavity. 

Escape  of  fluid  into  the  peritoneum  is  an  undisputed  cause  of  this,  as  of 
general  peritonitis.  I  myself  produced  a  well-marked  case,  which  almost 
terminated  fatally,  by  injecting  a  solution  of  persulphate  of  iron  into  the 
uterine  cavity.  The  passage  of  the  fluid  through  the  tubes  could  not  be 
questioned,  for  agonizing  pain  came  on  in  less  than  three  minutes,  and 
continued  up  to  the  development  of  inflammation.  This  danger  has  caused 
the  almost  entire  abandonment  of  intra-uterine  injections  on  the  part  of  the 
majority  of  practitioners,  unless  the  cervix  be  previously  dilated  by  tents. 
But  many  other  sources  from  which  fluid  may  enter  the  peritoneum  exist ; 
as,  for  example,  rupture  of  an  ovarian  cyst,  discharge  of  tubal  dropsy,  or 
of  a  pelvic  abscess,  intra-peritoneal  hemorrhage,  regurgitation  of  obstructed 
menstrual  blood,  etc. 

Traumatic  agencies,  as  blows,  falls,  injury  during  labor,  punctures,  etc., 
may  result  in  partial,  as  they  do  in  general,  inflammation  of  the  perito- 
neum. 

During  the  performance  of  menstruation,  a  physiological  function  which 
involves  ovarian  rupture  and  produces  hemorrhage,  which  must  pass  to 
the  uterus  by  a  narrow  tube  not  permanently  in  immediate  contact  with 
the  ovary,  any  degree  of  exposure  must  evidently  tend  to  inflammation  in 
the  investing  peritoneum.  Of  M.  Bernutz's  99  cases,  20  were  thus  pro- 
duced. 

Tubercles  deposited  in  the  part,  either  on  the  peritoneum  or  in  the 
tissue  of  the  tubes  or  uterus,  may,  as  they  do  elsewhere,  result  in  secondary 
inflammation  ;  and  cancerous  or  cancroid  degeneration  would  be  still  more 
likely  to  produce  the  same  result. 

In  certain  peculiar  states  of  the  system  this  affection  is  excited  by  the 
most  trivial  circumstances,  and  very  commonly  the  physician  is  held  to  a 
severe  account  for  the  fatal  issue  of  an  affection  which  he  as  little  expected 
to  arise  from  his  interference  as  the  friends  of  the  patient  did.  I  have 
seen  it  excited  by  the  passage  of  the  uterine  sound,  the  use  of  a  small 
sponge  tent,  and,  in  one  case,  from  the  passage  of  water,  used  by  vaginal 
injection,  into  the  uterus.  Dr.  Barnes,  in  his  late  excellent  work  on  the 
"Diseases  of  "Women,"  says,  "I  have  seen  fatal  peritonitis  fol'ow  the 
simple  application  of  nitrate  of  silver  to  the  cervix  uteri."  It  should  bo 
the  duty  of  every  physician  to  shield  an  unfortunate  brother  practitioner 


VARIETIES  —  SYMPTOMS.  403 

by  the  protection  which  these  facts  legitimately  afford  him  ;  but  it  should 
equally  be  the  duty  of  each  to  remember  tins  paragraph,  the  whole  of 
which  is  italicized  in  Dr.  Savage's  work  upon  the  Female  Sexual  Organs 
— "  No  surgical  proceeding  whatever,  touching  any  part  of  the  uterine 
system,  should  be  unattended  by  the  precautions  observed  in  operations  of 
a  grave  character  there  or  elsewhere  ;  in  certain  states  of  the  general 
system,  unforeshadowed  by  any  recognizable  peculiarity,  the  most  trivial 
operation  has  been  speedily  followed  by  fatal  peritonitis." 

Varieties This  affection  may  assume  either  an  acute  or  chronic  form, 

though  when  it  constitutes  the  principal  disease  it  generally,  in  the  begin- 
ning, presents  the  features  of  the  former.  When  it  occurs  as  a  complica- 
tion of  tuberculosis  or  uterine  disease,  it  often  assumes  from  the  beginning 
the  chronic  type.  Besides  these  varieties  there  are  two  others  which  can- 
not be  passed  without  notice — menstrual  pelvic  peritonitis  which  becomes 
aggravated  at  periods  of  ovulation,  and  recurrent  peritonitis  which  lasts 
for  many  years,  giving,  however,  immunity  for  long  periods,  and  then 
recurring  with  great  violence  from  a  trivial  cause.  I  have  had  several 
such  cases,  one  of  which  lasted  ten  and  another  eight  years.  For  eight, 
ten,  or  twelve  months  these  patients  enjoy  an  almost  absolute  immunity 
from  the  disorder :  then,  excited  by  some  apparently  insignificant  cause, 
a  severe  and  excessively  painful  attack  comes  on.  Sometimes  these 
attacks  are  complicated  by  cellulitis,  and  a  purulent  accumulation  fre- 
quently discharges  itself  through  the  pelvis  as  a  consequence  of  them. 
Symptoms The  acute  form  shows  itself  by — 

Pelvic  pain  and  tenderness  ; 

Sometimes  great  vesical  irritation  ; 

Usually  increased  thermometric  range  ; 

Nausea  and  vomiting  ; 

Anxious  facies  ; 

Mental  disturbance ; 

Tympanites. 
"When  a  severe  acute  attack  sets  in,  it  may  cause  either  a  chill,  or  a 
sensation  of  coldness  so  slight  that  the  patient  will  not  recall  its  occurrence 
unless  her  attention  be  especially  directed  to  it ;  or  pain  and  fever  may 
show  themselves  without  this  symptom. 

Pain  is  at  times  only  moderate,  but  at  others  most  severe.  It  may 
occur  in  paroxysms,  which  create  the  greatest  agony  and  prostrate  the 
patient  by  their  severity.  I  have  seen  it  amount  to  agony  equal  to  that 
arising  from  the  passage  of  a  biliary  calculus,  causing  the  patient  to  roll  in 
bed,  seize  the  bedclothes  in  the  teeth,  and  cry  aloud  most  piteously.  As 
a  rule,  it  is  not  so  violent  as  this.  Pain  may  show  itself  quite  early  in 
the  disease,  or  may  be  preceded  for  several  days  by  pelvic  uneasiness  and 
weight. 

Tenderness  over  the  whole  hypogastrinm  accompanies  it  to  such  a  de- 


494  PELVIC    PERITONITIS. 

gree,  that  even  the  weight  of  the  bedclothes  is  intolerable,  and  the  patient, 
to  relieve  it,  lies  upon  the  back  with  the  legs  flexed  in  order  to  relax  the 
abdominal  muscles. 

The  pulse  shows  in  slight  cases  very  little,  and  in  severe  cases  a  con- 
siderable amount  of  febrile  action.  It  is  small  and  wiry,  and  increases  in 
rapidity  to  1 10  or  120  to  the  minute. 

The  thermometric  range  is  likewise  variable.  In  the  beginning  of  an 
attack,  which  may  become  a  severe  one,  the  range  may  be  normal,  or 
even  below  the  normal  standard.  *'  Sub-normal  temperatures  are  espe- 
cially common  in  peritonitis,"  says  Wunderlich,  "  and  always  suspicious ; 
death  may  follow  them  closely.  High  and  rising  temperatures  do  not  add, 
per  se,  arguments  for  an  unfavorable  termination,  although  adding  another 
dangerous  element  to  the  case.  It  is  not  so  much  the  actual  height,  as  its 
constancy,  which  must  be  feared  ;  as  are,  also,  great  and  irregular  fluctua- 
tions between  very  high  and  very  low  temperatures."  When,  however,  a 
case  commences  with  a  temperature  of  106°,  it  is  greatly  to  be  feared  that 
it  will  run  a  violent  and  dangerous  course.  On  the  other  hand,  even  a 
normal  temperature  should  not  give  complete  security,  although  a  decidedly 
favorable  augury  may  usually  be  drawn  from  it.  In  general  terms  it  may 
be  said  that  for  him  who  implicitly  trusts  to  the  revelations  of  the  thermo- 
meter in  this  affection,  it  will  prove  an  unreliable  guide ;  but  to  him  who 
looks  upon  them  merely  as  aids  to  diagnosis  and  prognosis,  it  will  give 
decided  assistance. 

Nausea  and  vomiting  are  common  symptoms,  though  they  do  not  gene- 
rally exist  to  such  a  degree  as  to  prove  very  annoying. 

The  facies  is  peculiarly  anxious,  and  is  sometimes  rendered  very  striking 
by  the  appearance  of  dark  circles  around  the  eyes. 

I  have  generally  noticed  in  acute  cases  that  the  mind  is  markedly  dis- 
turbed, as  if  the  patient  instinctively  dreaded  some  serious  disease,  and 
even  in  chronic  cases  there  is  a  decided  tendency  to  slight  mental  aliena- 
tion.    In  several  cases  I  have  seen  this  advance  to  absolute  insanity. 

It  may  be  justly  observed  that  these  are  the  symptoms  which  mark 
general  peritonitis.  This  is  true  ;  it  is  merely  the  slighter  degree  of 
severity  and  the  localization  of  pain  and  tenderness,  which  will  point  to 
the  partial  nature  of  the  affection. 

With  reference  to  general  peritonitis,  it  may  be  stated  that,  on  the  one 
hand,  it,  of  all  diseases,  may  declare  itself  by  the  most  numerous  and 
characteristic  symptoms,  or,  on  the  other,  run  its  fearful  course  with  the 
greatest  obscurity,  so  as  to  mislead  the  most  careful  diagnostician,  even  up 
to  its  latest  stages.  If  this  be  true  as  to  the  general  disorder,  how  much 
more  must  it  be  so  as  to  the  local.  Thus  it  is  that  we  find  the  subacute 
and  chronic  forms  passing  off  without  recognition,  and  the  fact  that  they 
have  existed  is  known  only  by  the  discovery  of  firm  adhesions  over  the 


PHYSICAL    SIGNS.  405 

whole  pelvic  roof  in  post-mortem  examinations.  In  these  varieties,  there 
is  less  pain  and  tenderness  and  less  tendency  to  nausea  and  febrile  action 
than  in  the  acute.  Sometimes,  indeed,  there  is  merely  a  sense  of  local 
discomfort,  increasing  to  pain  at  menstrual  periods,  accompanied  by  fever 
towards  evening,  by  difficulty  in  locomotion,  and  by  a  general  sense  of 
feebleness  and  malaise.  This  remarkable  absence  of  symptoms  in  pelvic 
peritonitis  was  announced  by  Aran,  and  Dr.  Duncan1  expresses  himself 
upon  it  in  these  words :  "  I  might  adduce  cases  of  gonorrhccal  ovaritis 
commencing  in  healthy  young  girls,  and  ending  in  the  fusion  of  all  the 
parts  in  the  pelvis  into  a  solid,  immovahle  mass,  without  the  patient  losing 
a  cheerful,  and  even  gay  visage,  or  making  any  great  complaint  of  pain, 
unless  interrogated  closely,  and  then  alleging  the  chief  suffering  to  be  from 
irritahle  bladder." 

Physical  Signs Should   an   examination   be   made   during    the   first 

stage,  nothing  will  be  ascertained  but  the  existence  of  sensitiveness  upon 
pressure  in  the  vaginal  cul-de-sac  and  upon  lifting  the  uterus.  Tender- 
ness will  likewise  be  demonstrated  by  pressure  on  the  hypogastrium. 
None  of  that  doughy,  oedematous,  puffy  feel  which  accompanies  cellulitis 
will  be  discovered  by  vaginal  touch.  Should  the  disease  run  its  course  as 
one  of  those  very  insignificant  attacks,  which  produce  no  grave  symptoms 
and  are  scarcely  recognizable,  no  other  physical  signs  will  present  them- 
selves at  this  or  any  other  period.  Should  it  be  one  of  graver  character, 
a  sense  of  resistance  merely,  or  a  tumefaction  like  an  ill-defined  tumor, 
may  be  felt  in  the  recto-vaginal  space  or  at  the  side  of  the  uterus.  Or  if 
very  little  lymph  and  much  sero-pus  have  been  the  result  of  the  inflamma- 
tory action,  a  sense  of  fluctuation  may  be  detected  very  early.  The  uterus 
is  always  more  or  less  interfered  with  in  its  mobility,  and  in  severe  cases 
it  is  absolutely  fixed.  This  explains  how  Lisfranc  and  Boivin  applied  to 
it  the  name  of  "fixity"  or  "immobility"  of  the  uterus. 

I  have  stated  that  a  tumor  is  commonly  felt  posterior  to,  or  at  one  side 
of  the  uterus.  This  tumor,  which  is  formed  by  agglutination  of  the  pelvic 
and  abdominal  viscera,  is  extremely  sensitive  to  touch. 

If  the  disease  go  on  to  formation  of  pus,  the  sense  of  tumefaction  may 
disappear  as  this  discharges,  itself;  but  if  the  effused  lymph  become 
thoroughly  organized,  it  remains  hard  and  resisting  for  a  length  of  time. 
This  accumulation  almost  invariably  displaces  the  uterus,  sometimes  by 
pressing  it  in  an  opposite  direction,  sometimes  by  drawing  it  towards  itself 
as  the  lymph  contracts. 

In  a  case  which  I  saw  some  years  ago  with  the  late  Prof.  G.  T.  Elliot, 
we  were  much  puzzled  for  a  short  time  before  its  fatal  issue,  by  the  exist- 
ence in  the  fornix  vaginas  of  a  pouch,  apparently  filled  with  fluid,  all  the 

1  "Perimetritis  and  Parametritis,"  p.  78. 


496  PELVIC    PERITONITIS. 

surrounding  parts  being  unattached  and  no  sense  of  tumefaction  or  resist- 
ance being  discoverable.  The  patient  died  suddenly  from  general  perito- 
nitis, and  upon  post-mortem  examination,  conducted  by  Prof.  J.  "VV".  S. 
Gouley,  we  found,  first,  a  small  piece  of  fetid  placento  in  utero,  the  result 
of  a  recent  abortion ;  second,  an  abscess  of  the  right  ovary,  which  had 
created  general  peritonitis  by  emptying  itself  into  the  peritoneum ;  and\, 
third,  pelvic  peritonitis,  which  had  evidently  existed  for  more  than  a 
week.  It  had  created  a  purulent  collection  in  Douglas's  cul-de-sac,  which 
was  limited  to  this  space  by  false  membranes,  that  formed  for  it  e  com- 
plete roof.  This  accumulation  it  was  which  gave  the  sensation  above 
described. 

In  another  case,  sent  to  me  by  Prof.  J.  C.  Hutchinson,  of  Brooklyn, 
the  uterus  was  found  firmly  bound  to  the  sacrum  by  a  hard,  resisting 
mass,  which  was  very  sensitive.  There  was  considerable  corporeal  endo- 
metritis, and  I  incautiously  applied  to  the  uterine  cavity  tincture  of  iodine, 
and  as  a  result  the  most  violent  pelvic  peritonitis  developed  itself,  which 
almost  became  general.  In  ten  days  after  its  inception,  a  soft,  fluctuating 
pouch  formed  in  the  fornix  vagina?,  which  became  so  painful  that  I  tapped 
it  with  an  exploring  needle  and  drew  off  about  an  ounce  of  clear  serum 
much  to  the  patient's  relief. 

Course,  Duration,  and  Termination. — In  no  disease  can  these  be  more 
variable  and  uncertain  than  in  that  under  consideration.  A  great  simi- 
larity exist3  between  its  phases  and  those  of  pleuritis.  As  in  that  affec- 
tion we  have  shades  of  difference,  varying  from  the  ordinary  "stitch  in 
the  side,"  which  results  from  inflammation  of  a  portion  of  the  pleura  not 
larger  perhaps  than  a  silver  half  dollar,  to  empyema  and  tubercular  pleu- 
ritis, which  may  continue  till  death  by  pulmonary  consumption  or  pneu- 
mothorax closes  the  scene,  so  may  we  have  in  pelvic  peritonitis  like 
variations.  It  may  run  its  course  unobserved,  leaving  evidence  of  its 
existence  only  in  adhesions  found  post  mortem.  It  may  pass  through  its 
first  two  stages  in  three  or  four  weeks,  leaving  the  uterus  permanently 
displaced  by  the  continuance  of  the  third.  It  may  reappear  with  a  certain 
amount  of  acuteness  at  menstrual  periods,  causing  them  to  be  very  painful. 
It  may,  if  due  to  tubercular  deposit,  continue  so  as  to  exhaust  the  patient 
slowly.  It  may  produce  a  purulent  collection,  which,  by  emptying  itself 
into  the  peritoneum  through  the  adhesions  thrown  around  it,  may  create 
general  peritonitis,  or  this  last  may  result  from  the  spread  of  morbid 
action  from  the  pelvic  to  the  general  serous  membrane. 

Differentiation The  diseases  with  which  this  is  most  likely  to  be  con- 
founded are — 

Periuterine  cellulitis  ; 

Pelvic  hematocele  ; 

Fibrous  tumors ; 

Fecal  impaction. 


DIFFERENTIATION.  497 

Periuterine  Cellulitis — Differentiation  between  these  two  affections  is 
in  some  cases  simple  enough,  but  in  others  it  is  impossible.  Difficulty  will 
occur  when  cellulitis  affects,  and  is  confined  to,  the  tissue  most  immediate 
to  the  uterus,  but  this  we  know  to  be  very  rare.  Our  suspicions  will  often 
be  turned  into  the  proper  channel  by  the  cause  of  the  attack.  Cellulitis 
will  very  rarely  occur  except  after  parturition,  abortion,  or  an  operation 
on  the  pelvic  viscera.  Peritonitis  will  usually  result  from  exposure  during 
menstruation,  disease  of  the  ovaries,  or  escape  of  fluid  into  the  peritoneum. 
Should  the  attack  occur  as  a  result  of  gonorrhoea,  it  is  probably  due  to 
serous  and  not  cellular  inflammation,  a  fact  which  the  anatomical  relations 
would  lead  us  &  priori  to  anticipate,  and  which  is  fully  substantiated  by 
statistics.  West  and  Aran  credit  gonorrhoea  with  the  causation  of  cellu- 
litis in  from  one  to  two  cases  in  a  hundred,  and  Bernutz  declares  it  active 
in  twenty-eight  out  of  a  hundred  of  peritonitis.  . 

Pelvic   Hematocele From   this  it  may  be  distinguished  by  the  great 

suddenness  of  appearance  of  hematocele,  absence  of  signs  of  inflammation 
in  the  beginning,  presence  of  those  of  hemorrhage,  and  by  the  much 
greater  dimensions  of  the  tumor,  which,  unlike  that  of  peritonitis,  is  at 
first  rather  soft  and  gradually  becomes  hard.  The  occurrence  of  free 
bloody  flow  will  likewise  point  to  hematocele,  though  such  an  occurrence, 
to  a  limited  extent,  often  takes  place  in  peritonitis.  Hematocele  often 
excites  peritonitis,  and  thus  both  frequently  exist  together. 

Fibrous  Tumors — These  will  generally  be  known  by  their  producing  no 
pain,  presenting  no  sensitiveness  on  pressure,  no  sense  of  oedema,  no  signs 
of  inflammation  nor  rapidity  of  development.  They  are  likewise  usually 
movable,  and  cause  no  fixation  of  the  uterus. 

Fecal  Impaction — After  pelvic  peritonitis  and  cellulitis  have  existed 
for  some  time,  and  have  lost  their  features  of  acuteness,  and  more  espe- 
cially after  opium  has  been  long  used  to  allay  the  pain  which  attends  them, 
they  are  very  apt  to  be  complicated  by  fecal  impaction.  Not  only  is  this 
a  complication,  I  have  known  it  exist  long  after  the  inflammatory  affection 
which  preceded  it  has  passed  away,  and  give  rise  to  the  belief  that  this 
still  continues,  the  pain  which  it  creates  being  attributed  to  the  primary 
condition.  I  have  met  with  several  very  striking  cases  in  which,  after 
four  or  five  months  of  intense  suffering  from  supposed  periuterine  inflam- 
mation, which  was  treated  by  free  use  of  opium,  I  discovered  great  fecal 
impaction,  the  removal  of  which  afforded  complete  and  permanent  relief. 
So  frequent  do  I  consider  the  development  of  this  condition  as  a  result 
and  complication  of  periuterine  inflammation,  or  as  an  independent  state 
which  is  mistaken  for  it,  that  I  never  take  charge  of  a  case  which  has 
been  under  the  previous  treatment  of  others  without  examining  for  its 
existence,  and  in  the  management  of  cases  from  the  commencement  under 
my  charge,  always  carefully  guard  against  its  occurrence. 
32 


498  PELVIC    PERITONITIS. 

Importance  of  differentiating  Peritonitis  from  Cellulitis. — The  impor- 
tance of  differentiating  this  disease  from  cellulitis  rests  in  part  upon  the 
fact  that  it  admits  of  less  local  interference.  Sometimes  the  passage  of  a 
uterine  sound,  an  application  to  the  cavity,  or  even  the  use  of  a  vaginal 
injection  which  hy  accident  has  entered  the  uterus,  has  been  known  to 
destroy  life  by  causing  peritonitis  which  has  extended  to  the  whole  perito- 
neum. It  is  likewise  important  in  reference  to  prognosis  as  to  the  course 
of  the  affection  and  its  remote  results.  Lastly,  it  should  not  be  forgotten 
that  progress  in  the  comprehension  of  the  diseases  of  all  organs  must  be 
preceded  by  a  careful  and  systematic  separation  of  them,  one  from  the 
other.  As  the  study  of  acute  cardiac  affections  under  the  common  name 
of  carditis  could  never  have  accomplished  what  that  of  each  of  its  varie- 
ties has  done,  so  could  not  investigation  of  these  affections,  undivided  into 
their  proper  classes. 

Prognosis If  the  case  follow  parturition  or  abortion,  the  prognosis 

will  be  rendered  graver  by  that  fact.  Otherwise  it  will  be  governed  in 
great  degree  by  the  general  symptoms.  Should  these  show  great  intensity 
of  inflammation,  and  constitutional  disturbance  be  evidenced  by  excessive 
nausea  and  vomiting,  quick  pulse,  anxious  facies,  etc.;  in  other  words, 
should  the  symptoms  point  to  the  probable  spread  of  the  disease  over  the 
whole  serous  sac,  the  ordinary  prognosis  of  peritonitis  may  be  made.  In 
cases  of  chronic  type,  occurring  in  the  non-puerperal  state,  it  5s  decidedly 
favorable,  unless  the  disease  exist  in  a  scrofulous  or  tuberculous  patient, 
or  show  a  tendency  to  severe  periodical  relapses.  Another  fact,  which 
will  increase  the  gravity  of  prognosis,  is  the  existence  of  purulent  effusion 
in  place  of  lymph  and  serum  as  the  result  of  the  inflammatory  action. 

Results The  common  results  of  the  disease,  which  remain  long  after 

it  has  passed  away,  or  perhaps  permanently,  are  injury  of  the  ovaries  by 
abscess  or  atrophy;  obliteration  or  dropsy  of  the  tubes  of  Fallopius ;  and 
fixation  of  the  womb  in  malposition,  by  organization  of  false  membranes. 
As  consequences  of  these  lesions  follow  very  naturally,  amenorrhoea,  dys- 
menorrhea, and  sterility. 

Treatment. — Pelvic  peritonitis  usually  announces  its  advent  by  severe 
pain,  elevation  of  temperature,  rapidity  of  pulse,  and  other  symptoms  which 
leave  the  practitioner  in  no  doubt  as  to  its  development.  The  rule  of 
treatment  should  be  based  upon  the  following  indications  :  first,  entire 
prevention  of  pain  during  its  course  ;  second,  complete  control  of  the  tem- 
perature ;  third,  the  strict  observance  of  absolute  quietude.  The  patient's 
prospect  for  life  and  for  escape  from  the  chronic  results  of  the  disease,  if 
recovery  occurs,  will  greatly  depend  upon  the  thoroughness  with  which 
these  indications  are  fulfilled. 

In  the  very  commencement  of  the  attack  pain  should  be  relieved  by 
opium  administered  by  the  hypodermic  syringe,  the  mouth,  or  the  rectum. 
The  first  method  is  an  excellent  one  to  begin  with,  but  its  frequent  use  ia 


DIFFERENTIATION.  499 

so  apt  to  engender  a  morbid  taste  that  it  is  better  after  pain  lias  once  been 
completely  subdued  to  continue  the  narcotic  influence  by  opium  or  morphia 
by  mouth  or  rectum.  But  opium  should  be  regarded  not  only  as  a  means  of 
relieving  pain,  it  aids  in  fulfilling  also  the  indication  of  preserving  perfect 
quietude,  and  limiting  inflammatory  action  by  its  influence  on  the  nervous 
system.  The  sovereign  remedy  for  peritonitis  is  opium,  not  in  small,  but 
in  large  and  repeated  doses,  carried  to  the  point  of  producing  the  quietude 
which  is  necessary  for  the  favorable  progress  of  the  case.  Sometimes  this 
condition  will  be  produced  by  one  grain  of  opium,  in  powder,  or  quarter 
of  a  grain  of  sulphate  of  morphia  every  two  or  three  hours,  but  in  many 
cases  half  a  grain  of  sulphate  of  morphia  will  be  repeated  every  two  or 
three  hours  for  a  long  time  before  perfect  ease  is  obtained.  The  inexpe- 
rienced employer  of  this  drug  in  these  doses  will  fear  dangerous  narcotism, 
but  in  New  York,  under  the  tuition  of  Alonzo  Clark,  to  whom  we  are  in- 
debted for  this  practice,  we  employ  it  with  the  greatest  confidence.  Let 
the  physician  avoid  all  other  drugs  and  give  opium  thus  freely  in  one  or 
two  cases  of  this  affection,  and  he  will  appreciate  its  value. 

In  a  certain  number  of  diseases  death  is  in  great  degree  due  to  the  very 
high  temperature  which  attends  them.  Examples  of  such  are  sunstroke, 
typhoid  fever,  septicaemia,  and  peritonitis.  In  all  these,  the  greatest  ad- 
vantage results  from  keeping  the  temperature  at  or  near  the  normal  stand- 
ard. This  being  done  the  altered  blood  state,  and  its  remote  influences 
upon  the  tissues,  composing  the  nervous  system  and  important  viscera, 
which  result  from  an  exaltation  of  the  animal  heat,  are  avoided,  and  thus, 
although  death  may  come  through  some  other  avenue  of  approach,  this  one 
is  obstructed.  The  best  method  of  controlling  high  temperature  is  cuta- 
neous refrigeration  by  Kibbee's  plan,  which  is  described  under  the  after- 
treatment  of  ovariotomy,  to  which  the  reader  is  referred  for  details  of  its 
practice. 

Perfect  quietude  should  be  observed.  Not  an  approximation  to  it,  but 
a  stillness  which  should  interdict  the  action  of  every  voluntary  muscle.  A 
nurse  should  watch  the  patient  night  and  day,  anticipate  every  want,  and 
supervise  every  function.  The  patient  should  not  converse  with  her,  and 
no  one  else  should  be  habitually  in  the  chamber.  The  bowels  will  be 
quieted  by  the  opium  employed.  No  cathartic  medicine  should  be  given,  as 
it  interferes  with  quietude,  and  it  is  well  to  keep  the  bladder  empty  by  the 
catheter,  if  urination  is  not  easy.  Milk,  beef-tea,  and  other  plain,  nutri- 
tious, and  unstimulating  food  should  be  prescribed,  but  no  solid  food  should 
be  allowed.  Should  the  pulse  be  strong,  rapid,  and  resisting,  the  tincture 
of  veratrum  viride  should  be  given  in  doses  of  five  drops,  in  water,  every 
four  hours,  until  the  specific  action  of  the  drug  is  developed. 

In  the  second  and  third  stages,  where  lymph  has  been  the  chief  and 
perhaps  the  only  product  of  inflammation,  we  must  rely  upon  counter-irri- 
tants, and  I  know  of  none  to  be  compared  with  the  blister.     One  made  of 


500  PELVIC    PERITONITIS. 

Spanish  flies,  four  by  six  inches  in  dimensions,  should  be  applied  over  the 
hypogastrium  and  the  abrasion  which  it  produces  dressed  with  savine 
ointment.  As  soon  as  it  heals  entirely,  another  should  be  applied  directly 
over  the  newly-formed  skin,  and  this  may  be  repeated  every  ten  or  four- 
teen days  with  great  advantage.  I  have  known  patients  who  dreaded 
them  in  the  beginning  beg  for  them  after  experiencing  the  relief  which 
they  gave.  The  blister  is  to  pelvic  peritonitis  in  its  later  stages  what  it  is 
to  pleuritis,  the  most  rapid  and  efficient  of  remedial  agencies. 

Another  very  excellent  method  for  producing  counter-irritation  is  by 
tincture  of  iodine  painted  over  the  hypogastrium  once  in  twenty-four  hours 
for  weeks. 

Treatment  of  Chronic  Cases The  affection    having   passed    into  the 

chronic  stage,  or  originated  with  all  the  appearances  of  chronic  disease,  a 
different  course  of  management  becomes  advisable.  The  patient  should 
not  be  so  strictly  confined  to  bed  nor  dieted.  She  has  entered  upon  an 
invalid  course  which  may  last  for  months  or  for  years,  and  in  making  a 
strenuous  effort  to  cure  her  local  disorder  we  may  sap  her  general  health 
and  do  her  irretrievable  injury.  On  the  other  hand,  she  should  not  attend 
to  her  household  cares,  nor  take  exercise  to  any  great  degree  ;  but  remain- 
ing in  bed  or  on  a  lounge  most  of  the  time,  go  out  in  the  fresh  air  for  an 
hour  or  two  daily.  Her  diet  should  be  of  the  most  nutritious  character, 
stimulants  should  be  allowed  in  moderation,  and  the  impoverished  blood 
resulting  from  a  combination  of  circumstances  prejudicial  to  hematosis, 
combated  by  change  of  air  and  the  use  of  vegetable  and  mineral  tonics, 
especially  iron. 

One  of  the  most  important  questions  in  the  management  of  chronic 
cases  is  that  of  the  amount  of  exercise  to  be  allowed,  and  the  strictness  of 
confinement  to  be  practised.  No  absolute  rule  can  be  laid  down  in  refe- 
rence to  these  points,  for  each  case  will  call  for  special  guidance,  based 
upon  careful  experiment.  In  general  terms  it  may  be  stated  that  when 
motion  does  not  produce  pain  or  discomfort,  the  patient  should  ride  in  an 
easy  carriage  for  two  or  three  hours  daily.  In  those  cases  which  are  still 
more  free  from  local  trouble,  she  may  walk  with  moderation  ;  while  in 
others  which  present  elements  of  acuteness,  no  motion  whatever  should  be 
allowed.  Sometimes  the  patient  will  even  bear  removal  from  home  to  the 
sea-side  or  some  watering-place  during  the  summer.  If  this  be  so,  a  locality 
should  be  chosen  that  is  accessible  by  easy  travel.  One  great  and  ever 
recurring  difficulty  in  this  connection  arises  from  the  great  tendency  of 
patients,  allowed  to  take  exercise,  to  commit  indiscretions  by  overtaxing 
themselves.  This  becomes  so  great  at  times,  as  to  make  it  advisable  to 
confine  to  bed  one  who  would  be  benefited  by  moderate  exercise,  in  order 
to  avoid  danger  from  her  imprudence.  The  fact  should  never  be  lost  sight 
of  that  the  pelvic  peritoneum  forms  a  part,  a  sheath,  as  it  were,  of  the 
suspensory  ligaments  of  the  uterus.     The  fibrous  structure  of  the  round, 


DIFFERENTIATION.  oQl 

broad,  sacral,  and  vesical  ligaments  is  covered  by  it,  so  that  drairgin"  of 
the  uterus  upon  them  puts  the  peritoneum  upon  the  stretch  and  strongly 
tends  to  excite  renewed  action  there. 

Of  all  influences  which  act  in  a  directly  prejudicial  manner  upon  these 
cases,  sexual  intercourse  is  the  most  decided,  and  its  strict  limitation 
should  be  made  one  of  the  first  rules  laid  down  for  their  management. 

Should  acute  exacerbations  occur  in  chronic  cases,  the  use  of  local  de- 
pletion is  advised  by  high  authority;  but,  as  a  plan  to  be  strictly  pursued 
with  reference  to  cure,  it  is  highly  objectionable  on  account  of  the  spanajmia 
■which  it  induces. 

If  it  be  deemed  advisable  to  keep  up  the  use  of  the  iodide  or  bromide  of 
potassium,  the  results  of  which  are,  however,  doubtful,  they  may,  with 
advantage,  be  combined  with  iron  and  vegetable  tonics,  as  in  the  following 

prescriptions : — 

I£.  Potassii  iodidi,  5iij- 
Ferri  iodidi  syr.  ^'j- 
Tr.  calombse,  jjvj. — M. 
A  dessertspoonful  (3'j)  in  water  three  times  a  day. 

$.  Potassii  bromidi,  5V- 
Vini  ferri  dulcis,  §iv. 
Tr.  calombae,  §iv. — M. 
A  dessertspoonful  in  water  three  times  a  day. 

Should  collections  of  pus  or  serum  be  evacuated  f  The  important  bear- 
ings of  this  question  are  manifest,  but  unfortunately  no  definite  answer 
can  be  given  to  it.  In  evacuating  these  collections  the  peritoneal  cavity 
is  not  exposed  to  entrance  of  air,  for  a  false,  membranous  roof  covers  the 
collection,  but  there  is  always  danger  in  perforating  the  delicate  and  easily 
inflamed  serous  sac.  I  have  elsewhere  reported  a  case  in  which  I  drew 
off  one  or  two  ounces  of  serum  under  these  circumstances,  to  the  great 
relief  of  the  patient,  who  rapidly  improved  and  did  well.  It  is  not  the 
only  case  in  which  I  have  ventured  to  invade  the  peritoneum  under  these 
circumstances.  The  safest  rule  for  practice  will  be  this :  if  in  spite  of  the 
sero-purulent  collection  the  patient  be  doing  well  and  do  not  suffer  from 
the  local  trouble,  it  should  be  left  to  empty  itself  spontaneously.  If,  on  the 
other  hand,  the  patient  suffer  from  the  collection,  be  not  progressing  favor- 
ably, and  the  evacuation  be  perfectly  practicable,  it  should  be  accomplished. 

Methods  of  Evacuation.  —  Evacuation  may  be  accomplished  by  the 
aspirator,  a  small  trocar  and  canula,  or  by  a  guarded  bistoury  or  tenotomy 
knife.  After  evacuation  the  sac  may  be  carefully  washed  out  with  a 
weak  solution  of  carbolic  acid  in  warm  water,  or  of  tr.  of  iodine  in  the 
same  menstruum. 


502  PELVIC  ABSCESS. 


CHAPTER    XXXII. 

PELVIC  ABSCESS. 

Surprise  may  be  felt  at  the  appropriation  of  a  special  chapter  to  this 
subject.  The  opinions  of  several  reviewers  have  already  been  expressed 
to  this  effect,  and  the  propriety  of  making  it  an  addendum  to  that  on 
cellulitis  or  peritonitis  has  been  suggested.  How  could  this,  however, 
with  propriety  be  done,  when  pelvic  abscess  arises  from  other  than  those 
inflammatory  processes;  from  ovaritis,  perirectitis,  psoas  disease,  disease 
of  the  pelvic  bones,  etc.?  It  appears  to  me  a  matter  of  importance  to 
impress  the  fact  that  it  should  be  viewed  from  a  more  general  standpoint 
and  not  be  limited  to  the  results  of  two  affections.  I  know  of  no  surer 
way  of  effecting  this  object  than  that  which  I  here  pursue. 

Definition. —  Upon  this  point  little  need  be  said,  as  any  purulent  col- 
lection originating  in,  and  not  simply  passing  through,  the  pelvis,  comes 
under  this  head,  regardless  of  its  cause. 

Pathology. —  There  are  three  sources  of  pelvic  abscess:  1st,  break- 
ing down  of  tuberculous  material  deposited  in  any  of  the  tissues  of 
the  pelvis;  2d,  suppurative  action  taking  place  in  the  walls  of  a  cavity 
formed  by  an  hematocele  or  ovarian  cyst ;  3d,  inflammatory  suppuration 
in  the  areolar  tissue,  the  ovaries,  the  tubes,  the  pelvic  peritoneum,  or  the 
parenchyma  of  the  uterus  itself.  Of  all  these  sources  the  third  is  decidedly 
the  most  frequently  met  with,  and  is  most  generally  the  result  of  cellulitis, 
occurring  after  parturition  or  in  the  non-puerperal  state.  Under  the  latter 
circumstances  cellular  inflammation  may  be  primary,  or  secondary  to  irri- 
tation from  some  foreign  body,  as  the  debris  of  an  extra-uterine  foetus,  a 
hard  substance  in  the  vermiform  appendix,  a  fibrous  tumor  of  the  uterus, 
or  caries  of  the  pelvic  bones. 

Causes. — Any  influence  which  induces  cellulitis,  or  either  of  the  other 
two  pathological  conditions  mentioned,  may  prove  immediately  causative 
of  abscess.  As  remote  causes  may  be  mentioned  the  tuberculous,  scrofu- 
lous, and  syphilitic  diathesis ;  great  depression  of  the  vital  energies  from 
any  cause,  as  impure  air,  like  that  of  a  hospital ;  the  puerperal  state ; 
and  pyrcmia. 

Symptoms. — These  will  not  differ  essentially  from  those  of  abscess  else- 
where. When  pus  is  forming,  violent  chills,  followed  by  fever,  with  pro. 
fu.se  sweating,  are  likely  to  occur.  Then  a  feeling  of  prostration  with 
throbbing  pain  in  the  pelvis,  pressure  upon  the  rectum  and  bladder,  and 
sometimes  interference  with  urination,  present  themselves.     Pain  down 


DIFFERENTIATION.  503 

the  thigh,  which  may  be  mistaken  for  sciatica,  will  also  at  times  be  no- 
ticed. 

Physical  Signs. — By  abdominal  palpation,  combined  with  rectal  or 
vaginal  touch,  a  fluctuating  tumor  will  be  felt,  presenting  the  ordinary 
physical  signs  of  purulent  collections  elsewhere. 

Course,  Duration,  and  Termination. — Pelvic  abscesses  may  evacuate 
themselves  through  any  part  of  the  floor  of  the  pelvis,  through  its  roof 
into  the  peritoneum,  through  any  one  of  its  walls  by  means  of  foramina, 
through  any  of  the  pelvic  viscera,  or  by  several  of  these  channels  at  the 
same  time.  They  may  open  by  free  outlet  or  by  a  long,  sinuous  tract, 
which  renders  prognosis  as  to  cure  extremely  grave.  The  most  favorable 
points  for  evacuation  are  through  the  vagina  and  rectum.  Next  to  these 
comes,  in  point  of  favorable  prognosis,  evacuation  through  the  abdominal 
walls.  Nonat  declares  that  when  the  collection  "opens  simultaneously 
into  the  intestine  and  bladder,  death  is  almost  inevitable."  In  the 
Charleston  Medical  Journal,  for  1853,  I  published  a  fatal  case  of  this 
character  with  autopsy.  Sometimes,  when  left  to  themselves,  these  ab- 
scesses will  go  on  to  recovery  without  delay,  opening  into,  and  discharging 
themselves  through  some  of  the  parts  mentioned,  and  gradually  contracting 
and  disappearing.  Sometimes,  if  deprived  of  the  assistance  of  art,  they 
may  burrow  deeply  into  the  tissues,  open  by  long,  fistulous  tracts  into 
some  organ,  as  the  large  intestine  or  sigmoid  flexure,  or  discharge  into 
the  peritoneum. 

Konig  has  instituted  some  very  interesting  experiments  on  the  cadaver, 
to  show  the  most  probable  routes  which  these  accumulations  may  take  : — 

1st.  Injecting  air  or  water  beneath  the  peritoneum  near  the  ovary  or 
tubes,  the  injection  ran  along  psoas  and  iliac  muscles  into  pelvis. 

2d.  Beneath  lateral  ligament  near  cervix,  it  filled  the  same  side  of  pelvis, 
ran  along  round  ligament  towards  Poupart's  ligament,  and  to  the  iliac  fossa. 

3d.  Beneath  broad  ligament  behind  cervix,  it  filled  posterior  and  lateral 
part  of  pelvis,  and  passed  along  psoas  and  iliac  muscles  into  pelvis. 

Sometimes,  even  when  the  opening  at  first  is  large,  it  contracts  so  as  to 
allow  only  an  imperfect  discharge  of  the  contents  of  the  sac.  Then  hectic 
fever  arises,  and  the  patient  either  leads  a  miserable  existence  for  years 
from  the  constant  fetid  flow,  or  is  worn  out  by  exhaustion  or  septicaemia. 
At  other  times  these  collections  of  pus  will  remain  imprisoned  for  a  long 
period,  without  any  attempt  at  escape. 

Differentiation. — The  morbid  states  with  which  this  condition  may  be 
confounded  are  these: — 

Pelvic  hematocele ; 
Extra-uterine  pregnancy; 
Displaced  ovarian  cyst; 
Hydrometra ; 
Tubal  dropsy. 


504  PELVIC    ABSCESS. 

The  first  of  these,  being  a  hemorrhage,  gives  certain  symptoms  charac- 
teristic of  that  accident,  as  prostration,  coldness  of  the  surface,  suddenness 
of  appearance,  etc.  ;  and  absence  of  chill,  heat,  fever,  and  other  signs 
which  are  likely  to  accompany  abscess. 

With  the  second,  the  signs  of  pregnancy  exist,  and  as  early  as  the  fourth 
month  foetal  movements  may  be  detected,  while  the  perfect  health  of  th  j 
patient  with  absence  of  menstruation  will  excite  suspicion  as  to  the  cha- 
racter of  the  affection. 

Around  abscesses,  even  of  tubercular  character,  there  is  always  a  wall 
of  lymph  thrown  up  which  would  not  be  present  in  a  displaced  ovarian 
cyst.  All  the  rational  signs  of  suppuration  would  likewise  be  absent  in 
the  latter. 

He  who  confounds  the  distended  body  of  the  womb  with  abscess  would 
surely  be  very  culpable,  for  the  spherical  shape  of  the  body  and  the  light 
obtainable  from  the  uterine  probe  should  be  guides  by  which  to  avoid  error 

Tubal  dropsy  is  generally  the  result  of  inflammatory  action  affecting  the 
Fallopian  tubes  and  closing  both  uterine  and  ovarian  extremities,  at  the 
same  time  that  it  causes  a  secretion,  which  distends  the  intermediate 
canal.  The  fluctuating  tumor  thus  resulting,  being  produced  by  inflam- 
mation, and  being  often  attached,  in  consequence,  to  the  surrounding  parts, 
would  offer  difficulties  in  diagnosis  which  might  well  prove  insurmount- 
able.    If  an  error  were  made,  however,  no  evil  would  result  from  it. 

Prognosis The  prognosis  will  depend  upon  the  following  circum- 
stances :  It  will  be  favorable  if  the  abscess  be  superficial,  point  upon  a 
mucous  tract,  open  low  down  in  the  pelvis  by  free  exit,  and  give  forth  pus 
which  has  no  offensive  odor.  Should  it  be  deep-seated,  open  by  a  long 
tract,  give  forth  fetid  pus,  open  high  up  and  by  two  points  of  exit,  as,  for 
example,  the  bladder  and  bowel,  the  prognosis  is  decidedly  unfavorable, 
unless  the  case  can  be  so  affected  by  surgical  interference  as  to  change  its 
character. 

Treatment. — Nothing  can  be  done  in  these  cases  by  specific  medication, 
by  which  I  mean  that  directed  especially  to  relief  of  the  existing  morbid 
condition.  All  of  our  efforts  should  be  directed  to  supporting  the  vital 
forces,  which  are  always  much  prostrated  by  the  process  of  suppuration. 
The  patient  should  take  the  most  nutritious  diet,  as  much  animal  food  as 
she  can  digest,  eggs,  milk,  fresh  vegetables,  and  malt  liquors.  "Whiskey 
or  brandy  should  be  allowed  her,  and  the  blood  state  should  be  improved 
as  much  as  possible  by  vegetable  and  mineral  tonics.  Those  most  espe- 
cially suited  to  the  condition  are  preparations  of  cinchona,  and  of  iron,  as, 
for  instance,  the  following  pill : — 

§. — Quinise  sulphat.  9ij. 

Ferri  sulphat.  9j. 

Acid,  sulph.  arom.  gtt.  x. 

Mucilage  acaci<*e,  q.  s. — M.  ot  ft.  pil.  No.  xx. 
S. — One  to  be  taken  three  times  a  day  before  meals. 


TREATMENT.  505 

But  it  is  to  surgery  that  we  must  look  most  confidently  for  aid,  and  in 
this  connection  arises  the  important  question  as  to  the  propriety  of  open- 
ing such  abscesses,  the  best  point  for  evacuation,  and  the  time  for  inter- 
ference. 

Should  an  abscess  in  the  pelvis  show  a  rapid  tendency  to  point  and  dis- 
charge through  a  favorable  channel,  at  the  same  time  that  no  distressing 
or  dangerous  symptoms  show  themselves,  it  would  be  the  part  of  wisdom 
to  await  the  action  of  nature,  for  all  must  admit  that  there  are  few  locali- 
ties in  the  body  into  which  it  is  more  hazardous  to  cut  than  this.  Even 
under  these  circumstances,  however,  there  is  danger  in  delay.  Sir  James 
Simpson  relates  a  case  which  he  saw  with  Dr.  Zeigler  one  day  when  the 
abscess  pointed  decidedly  towards  the  vagina  and  rectum  very  low  down. 
Feeliiig  sure  that  it  must  soon  discharge,  they  left  it  till  the  next  day,  but 
before  that  time,  to  their  surprise,  it  had  burst  into  the  peritoneum.  This 
danger,  as  evidenced  by  statistics,  is  not  great,  and  as  experience  goes  to 
prove  that  the  knife  is  often  employed  too  early,  rather  than  too  late,  I 
should  strongly  recommend  the  delay  of  surgical  interference  until  the 
presence  of  pus  is  an  absolute  certainty.  If  it  be  thus  delayed,  the  tissues 
intervening  between  the  pus  and  the  point  of  introduction  of  the  instru- 
ment become  broken  down,  and  a  tract  or  sinus  is  avoided ;  if  two  or 
three  abscesses  exist  near  each  other,  we  give  time  for  them  to  coalesce  ; 
and  the  mass  of  lymph  poured  out  is  liquefied  by  the  suppurative  process. 
Should  evacuation  be  resorted  to  too  soon,  all  these  advantages  will  be  lost. 

Let  us  suppose  a  different  case,  that  the  patient  is  suffering  grave  con- 
stitutional signs  from  the  abscess.  The  answer  to  the  question  of  the  pro- 
priety of  interference  resolves  itself  into  this:  if  the  pus  can  be  certainly 
reached,  it  should  be  evacuated.  Should  the  abscess  be  deeply  seated,  on 
the  other  hand,  so  as  to  make  the  operation  difficult  and  uncertain,  it 
would  expose  the  patient  to  hazards  greater  than  those  attendant  upon 
delay. 

Dr.  Savage  believes  that  "  puncture  should  be  practised  early  and  per 
vaginam."  Spencer  Wells  declares  from  an  experience  in  opening  as 
many  as  from  twenty  to  thirty  pelvic  abscesses  that  he  has  known  of  no 
fatal  result.  "  I  have  known,"  says  he,  "several  cases  of  death  where  no 
puncture  has  been  made — some  of  them  very  painful  cases — when  I  had 
urged  puncture  and  was  overruled."     As  a  rule  he  punctures  per  vaginam. 

Prof.  Brickell,  of  New  Orleans,  has  recently  taken  strong  ground  in 
favor  of  the  early  evacuation  of  pelvic  accumulations,  and,  as  I  especially 
desire  to  lay  before  the  reader  an  unbiassed  view  of  the  present  state  of 
professional  opinion  upon  this  important  subject,  I  give  his  conclusions  in 
full  :— 

"1.  I  have  no  doubt  at  all  that  there  are  two  distinct  forms  of  pelvic 
inflammation — serous  and  phlegmonous,  or  suppurative.     An  attack  of 


506  PELVIC    ABSCESS. 

either  may  be  abortive — that  is,  may  fail  to  result  in  formation  of  pus  or 
effusion  of  serum.     But,  should  either  pus  or  serum  be  deposited,  then, 

2.  I  am  sure  that  evacuation  is  the  proper  practice;  and, 

3.  Either  should  be  evacuated  per  vaginam. 

4.  The  presence  of  pus  in  any  portion  of  the  body  is  not  to  be  tolerated 
by  the  surgeon.  I  contend  that  the  presence  of  effused  serum  in  the  pel- 
vis is  not  to  be  tolerated  either.  As  long  as  it  is  present,  in  addition  to 
the  pain  and  prostration  present,  there  is  the  abiding  stimulus  to  repeated 
inflammations,  and  the  pelvis  can  and  will  be  ravaged. 

5.  Topical  applications  and  internal  remedies  have  no  influence  on 
pelvic  and  serous  effusions,  according  to  my  observation." 

For  my  part,  I  feel  very  sure  that  this  subject  is  one  upon  which  no 
fixed  rule  can  be  given.  The  surgeon  must  weigh  the  dangers  of  opera- 
tion with  those  of  delay,  and  decide  by  the  indications  presenting  in  each 
individual  case.  Were  the  determination  of  the  existence  and  locality  of 
purulent  accumulation  really  as  easy  at  the  bedside  as  one  might  be  led 
to  regard  it  from  the  literature  of  the  subject,  I  should  strongly  advocate 
a  uniform  resort  to  evacuation.  But  this  not  being  by  any  means  the 
case,  I  am  induced  to  do  otherwise.  Nor  must  it  be  imagined  that  seek- 
ing for  pus  hidden  away  in  the  pelvic  areolar  tissue  is  an  entirely  safe 
procedure.  The  following  fatal  case,  due  in  all  probability  to  an  entrance 
of  air  into  the  veins,  will  prove  interesting  in  this  connection: — 

"In  the  case  reported,1  aspiration  some  three  months  before,  for  the 
removal  of  a  quantity  of  pus  from  the  pelvis,  had  been  followed  by  much 
relief.  The  symptoms  having  returned,  the  needle  was  again  introduced 
through  the  vagina  to  the  left  of  the  uterus,  a  distance  of  three-fourths  of 
an  inch.  As  soon  as  the  pumping  was  commenced  the  patient  manifested 
pain,  became  convulsed,  and  grew  purple.  Congestion  of  all  the  superfi- 
cial veins  followed,  though  the  needle  was  immediately  withdrawn  as  soon 
as  the  symptoms  began,  when  no  more  than  four  or  five  strokes  had  been 
made.  In  three  minutes  the  patient  was  comatose,  and  in  ten  minutes 
the  heart  ceased  to  pulsate. 

"The  autopsy  revealed  a  small  punctured  wound  on  the  left  side  of  the 
vagina,  one  and  a  half  inches  before  its  juncture  with  the  uterus.  The 
probe  passed  upward  and  to  the  left  three-fourths  of  an  inch  in  the  direc- 
tion of  a  soft  tumor  in  the  uterus.  Around  the  track  followed  by  the 
probe  was  no  more  than  a  teaspoonful  of  clotted  blood.  A  close  network 
of  small  veins  was  traversed  by  the  puncture  just  outside  of  the  vagina, 
but  after  the  most  diligent  search  it  was  seen  that  no  important  bloodvessel 
had  been  touched.  The  areolar  tissue  about  the  uterus  contained  air. 
The  left  lung  was  much  congested.  The  right  chambers  of  the  heart 
were  filled  with  air,  and  contained  no  blood.     The  left  chambers  were 

1  Boston  Med.  and  Surg.  Journ.,  vol.  cii.  No.  17. 


TREATMENT.  507 

empty.  The  valves  were  normal.  The  veins  of  the  stomach  were  dis- 
tended with  air,  presenting  the  appearance  of  pale  round  worms." 

The  Best  Point  for  Evacuation. — To  whatever  surface  the  point  of  the 
abscess  is  nearest,  that  will,  as  a  general  rule,  be  the  best  for  its  evacua- 
tion. If  there  be  a  choice,  the  locations  at  which  it  will  most  likely 
point  should  be  chosen  in  this  order:  1st,  the  vagina;  2d,  the  rectum; 
3d,  the  abdominal  walls. 

Dr.  Savage  reports  the  points  of  opening,  artificial  or  spontaneous,  in 
19  cases;  they  were  as  follows: — 

1  above  pubes  at  median  line. 

1  midway  between  navel  and  pubes. 

1  outside  left  saphenous  opening. 

2  by  rectum  ;  1  fatal. 
1  by  rectum  and  side  of  anus. 

1  by  colon  ;  1  fatal. 
4  by  vagina. 

2  by  bladder. 

1  by  iliac  region. 

3  into  peritoneum  ;  3  fatal. 

1  by  rectum  and  internal  abdominal  ring. 

1  by  vagina,  bladder,  rectum,  and  inguinal  region. 

It  will  be  seen  that  out  of  19  cases  5  proved  fatal — 3  by  emptying  into 
the  peritoneum,  and  2  by  causing  colitis  and  rectitis. 

Methods  of  Operating — The  propriety  of  opening  the  abscess  having 
been  determined  upon,  the  operator,  if  he  intend  reaching  it  through  the 
vagina  or  rectum,  should  carefully  investigate,  by  touch,  as  to  the  pres- 
ence upon  their  walls  of  large  bloodvessels,  the  opening  of  which  might 
prove  a  source  of  serious  hemorrhage.  The  patient  being  placed  on  the 
left  side  and  Sims's  speculum  introduced,  if  there  exist  the  slightest  doubt 
as  to  the  contents  of  the  sac  the  needle  of  a  hypodermic  syringe  should  be 
plunged  into  it  and  the  point  decided.  If  this  be  not  done,  an  ordinary 
exploring  needle  should  be  passed  into  the  tissues  until  pus  is  seen  to  flow 
along  its  groove.  Then  the  operator,  feeling  sure  of  his  ability  to  reach  pus, 
holds  the  needle  in  one  hand,  while  with  the  other  he  slides  the  point  of  a 
bistoury  along  its  gutter  and  passes  it  to  the  place  of  accumulation.  This 
is  a  method  at  once  safe,  certain,  and  effectual,  and  I  should  recommend 
it  in  preference  to  any  other  except  that  which  comes  next  to  be  consid- 
ered. The  aspirator  affords  an  easy  and  effectual  means  of  emptying 
these  accumulations,  and  at  the  same  time  one  that  is  to  a  great  extent 
free  from  danger.  After  it  has  removed  all  the  fluid  which  will  flow,  its 
action  may  be  reversed,  the  sac  filled  with  warm  carbolized  water,  and 
this  at  once  drawn  off  again.  Should  reaccumulation  take  place,  the 
situation  and  certainty  of  the  purulent  collection  being  established,  it  may 
be  evacuated  by  a  bistoury.  If  the  opening  made  be  large  enough  to 
admit  the  finger,  it  should  be  passed  in,  and  by  it  any  tract  leading  into 


508  PELVIC    ABSCESS. 

an  adjoining  abscess  should  be  enlarged,  and  any  sloughing  tissue  met, 
removed.  After  this,  should  there  be  any  fear  of  closure  of  the  canal  just 
opened,  its  walls  may  be  touched  by  nitrate  of  silver,  or  painted  with 
solution  of  persulphate  of  iron,  or  a  piece  of  gum-elastic  catheter  or  rubber 
tubing  may  be  left  in  it. 

If  it  be  thought  best  to  select  the  abdominal  surface  as  the  point  of 
evacuation,  all  danger  of  escape  of  pus  into  the  peritoneum  may  be 
avoided  by  following  the  suggestion  of  Recamier  with  reference  to  hepatic 
cysts,  namely,  causing  adhesions  of  the  layers  of  the  serous  membrane  by 
a  nitric  acid  issue  over  the  point  of  selection.  A  trocar,  the  needle  of  the 
aspirator,  or  a  bistoury  guided  by  an  exploring  needle,  may  be  plunged 
through  the  centre  of  the  issue  without  the  danger  just  mentioned. 

Means  for  Causing  Closure  of  the  Sac Sometimes,  after  the  evacua- 
tion of  these  abscesses,  their  sacs  will  not  close,  but,  remaining  open  for 
months  and  even  years,  go  on  pouring  out  large  quantities  of  pus. 

The  causes  of  their  not  closing  are  these:  the  existence  of  sinuses, 
which  will  not  allow  their  complete  evacuation  ;  a  peculiar  condition  of 
their  walls  from  the  existence  of  a  membrane,  called  by  Delpech  pyogenic, 
which  tends  to  prolong  suppuration  ;  or  the  passage  into  the  sac  of  air  or 
feces  from  the  intestines,  or  urine  from  the  bladder. 

Of  these  the  first  is  decidedly  the  most  frequent,  and  should  be  met  by 
dilatation  of  the  tract  leading  to  the  abscess,  by  tents  of  laminaria,  or 
enlargement  by  the  knife. 

Should  the  abscess  have  a  short  and  free  outlet,  the  sac  should  be 
injected  two  or  three  times  a  week  with  tincture  of  iodine,  at  first  in 
solution,  afterwards  pure  ;  or  by  solution  of  carbolic  acid. 

In  case  of  entrance  of  feces,  air,  or  urine  into  the  diseased  part,  a 
counter-opening  should  be  made  which  will  allow  their  free  escape,  and 
the  part  kept  as  clean  as  possible  by  injection  of  tepid  water.  Then  the 
fecal  or  urinary  fistula  allowing  the  vicarious  discharge  should  be  cured 
by  appropriate  means. 

Before  practising  any  operation  for  evacuation  of  pelvic  abscesses  an 
anaesthetic  should  always  be  administered,  as  perfect  quietude  is  essential 
to  safety. 


PELVIC    HEMATOCELE.  509 


CHAPTER  XXXIII. 

PELVIC  HEMATOCELE. 

Definition  and  Synonyms — Under  this  and  the  synonymous  titles  of 
retro-uterine  hematocele,  periuterine  hematoma,  and  bloody  tumor  of  the 
pelvis,  has  been  described  an  accumulation  of  blood  in  the  pelvic  cavity 
eitlier  above  or  below  the  peritoneum. 

History Although  an  attempt  has  been  made  to  prove  that  the  ancients 

were  cognizant  of  this  affection,  the  proof  of  such  a  fact  is  not  satisfactory. 
The  earliest  allusion  made  to  it  is  contained  in  the  works  of  Ruysch,  of 
Amsterdam,  who  wrote  in  1737.  After  this,  little  attention  was  paid  to 
it  until  the  time  of  Recamier,  although  mention  of  it  was  made  by  Frank, 
Deneux,  and  some  others. 

In  1831,  Recamier,  under  the  impression  that  he  was  opening  an  ab- 
scess, cut  into  a  tumor  behind  the  uterus  and  gave  exit  to  a  large  amount 
of  black,  grumous  blood,  and  about  ten  years  afterwards  Bourdon,  one  of 
his  pupils,  published  another  case  occurring  in  his  practice. 

A  tabular  view  of  the  names  of  those  who  have  been  chiefly  instru- 
mental in  elucidating  the  subject  and  sytematizing  our  knowledge  upon  it 
is  here  presented  : — 

Recamier,  1831,  "  Lancette  Francaise  ;" 

Velpeau,  1843,  "  Recherches  sur  les  Cavites  Closes  ;" 

Bernutz,  1848,  "  Archives  de  Medecine  ;" 

Vigues,  1850,  "  Des  Tumeurs  Sanguines  de  l'Excav.  Pelvienne  ;" 

Nelaton,  1851,  "Gazette  des  Hopiteaux  ;" 

Nonat,  1851,  "  These  de  Cestan,  Gallardo,  et  Prost  ;" 

Huguier,  1851,  Lecture  before  Surgical  Society  of  Paris  ; 

Gallard,  1855,  "  Union  Medicale  ;" 

Voisin,  1858,  "  De  l'Hematocele  Retro-Uterine." 

I  have  not  endeavored  to  record  the  names  of  all  who  have  made  valu- 
able contributions  in  France,  for  had  I  done  so,  the  list  would  have  been 
a  long  one.  Those  only  are  referred  to  who  have  been  foremost  in  ad- 
vancing our  knowledge. 

It  will  thus  be  seen  that  we  are  indebted  to  France  for  the  early  litera- 
ture of  pelvic  hematocele.  Germany  has  of  later  years  contributed  a  great 
deal  towards  it  through  the  labors  of  Olshausen,  Crede,  Braun,  Hegar, 
Virchow,  Schroeder,  Seiffert,  and  others;  and  England  through  those  of 
Madge,  McClintock,  and  Tuckwell.  In  America,  Prof.  Gunning  S.  Bed- 
ford reported  the  first  case  which  I  can  find  recorded.  More  recently,  we 
were  indebted  to  Dr.  Byrne,  of  Brooklyn,  for  a  faithful  report  of  several 


510  PELVIC    HEMATOCELE. 

cases.  Prior  to  the  year  1851,  although  it  had  attracted  some  attention, 
it  was  not  well  understood  even  in  France,  for,  in  1850,  we  find  Malgaigne 
cutting  into  a  hematocele  under  the  impression  that  he  was  enucleating  a 
fibrous  tumor,  and  losing  his  patient  from  hemorrhage. 

Frequency This  subject  is  not  fully  settled,  a  good  deal  of  discrepancy 

of  opinion  existing  concerning  it.  Prof.  Olshausen,  of  Halle,  declares 
that  in  1145  gynecological  cases  he  saw  34  hematoceles,  and  Seiffert,  of 
Prague,  reports  6G  seen  in  1272  cases  of  pelvic  female  diseases.  In  ten 
years  Dr.  Barnes  has  met  with  53  cases,  and  in  twenty  years  Dr.  Tilt  has 
seen  but  12. 

I  do  not  regard  the  disease  as  being,  by  any  means,  very  rare,  but  my 
experience  assures  me  that  many  cases  of  cellulitis  and  a  certain  number 
of  uterine  and  periuterine  tumors  are  reported  as  those  of  hematocele. 

Pathology. — The  definition  of  hematocele  has  no  relation  whatever  to 
the  cause  of  the  hemorrhage  which  gives  material  for  the  bloody  tumor. 
The  disease  consists  in  the  collection  of  a  mass  of  blood  in  the  pelvis, 
either  above  or  below  its  roof.  "Whatever  be  its  source,  such  a  collection 
constitutes  the  affection  which  engages  us.  Ordinarily,  we  find  that  the 
flow  giving  rise  to  it  takes  its  origin  from  one  of  the  three  following 
sources : — 

1st.  Direct  escape  of  blood  from  vessels  in  or  near  the  pelvis ; 

2d.  Reflux  of  blood  from  the  uterus  or  pubes ; 

3d.  Transudation  of  blood  in  consequence  of  dyscrasia  or  peritonitis. 

It  is  evident  that  hematocele  is  not  a  disease,  but  a  symptom  of  a  num- 
ber of  pathological  conditions.  As,  however,  the  source  of  the  hemor- 
rhage which  results  in  the  bloody  tumor  very  often  cannot  be  ascertained, 
we  are  forced  to  deal  with  its  most  prominent  and  significant  sign,  taking 
this  as  an  exponent  of  a  state  which  is  beyond  the  possibility  of  diagnosis. 

In  works  upon  practice  written  twenty  years  ago,  we  find  dropsy  treated 
of  as  a  disease.  In  those  of  to-day  it  is  regarded  only  as  a  legitimate  re- 
sult of  renal,  cardiac,  or  hepatic  disease.  Obstetric  writers,  even  as  late 
as  ten  years  ago,  described  puerperal  convulsions  as  a  disease  incident  to 
parturition.  Those  writing  ten  years  hence  will  probably  regard  them,  as 
many  do  to-day,  as  one  of  the  numerous  consequences  of  renal  disease. 
We  may  with  good  reason  hope  that  the  time  will  come  when  a  similar 
improvement  in  description,  based  upon  an  advance  in  our  knowledge  of 
pathology,  may  connect  itself  with  hematocele,  but  at  present  the  dis- 
covery of  the  source  of  the  hemorrhage  is  usually  impossible. 

The  special  sources  of  the  hemorrhage  inducing  the  affection,  which 
have  been  revealed  by  post-mortem  examinations,  may  thus  be  presented 
at  a  glance  : — 

1.   Rupture  of  bloodvessels  in  the  pelvis. 
Utero-ovarian  ; 
Varicose  veins  of  broad  ligaments  ; 


PATHOLOGY.  511 

Aneurism  of  artery  ; 

Vessels  of  extra-uterine  ovisac. 

2.  Rupture  of  pelvic  viscera. 

Ovaries ; 
Fallopian  tubes ; 
Uterus. 

3.  Reflux  of  blood  from  the  uterus. 

Reflux  of  menstrual  blood. 

4.  Transudation  from  bloodvessels. 

Purpura  ; 

Scorbutus ; 

Chlorosis  ; 

Hemorrhagic  peritonitis. 
All  of  these  causes  have  been  proved  by  post-mortem  research  to  have 
resulted  in  hematocele,  but  it  cannot  be  questioned  that  rupture  of  any 
bloodvessel  which  empties  its  contents  into  the  peritoneum  might  also  do 
so.  Blood  poured  into  the  peritoneum  from  rupture  of  the  spleen,  for  ex- 
ample, would  gravitate  towards  Douglas's  cul-de-sac,  because  it  is  the 
most  dependent  portion  of  that  membrane,  and  coagulating  would  give  all 
the  signs  of  a  bloody  tumor  in  that  locality.  At  times  the  affection  is  in- 
dicative of  serious  internal  lesion,  rupture  of  the  ovary  or  tube ;  at  others 
it  results  merely  from  imperviousness  of  the  cervical  or  tubal  canal,  which 
prevents  the  advance  of  menstrual  blood  and  causes  it  to  regurgitate  into 
the  peritoneum  ;  while  in  still  a  third  class  of  cases,  it  is  created  by  pour- 
ing out  of  blood  from  the  vessels  of  the  peritoneum.  The  last  condition 
has  been  described  as  hemorrhagic  peritonitis,  and  especially  pointed  out 
by  Virchow.  Schrceder  believes  that  peritonitis  always  precedes  the  oc- 
currence of  hematocele.  That  it  usually  accompanies  it  is  unquestionable, 
but  if  it  be  a  precursor  of  this  affection,  which  suddenly  bursts  forth  upon 
a  patient  apparently  in  good  health,  it  tells  badly  for  our  means  of  diag- 
nosis of  pelvic  peritonitis.  It  is  undeniable,  however,  that  in  some  cases 
hematocele  does  follow  and  not  precede  the  peritonitis. 

Whatever  be  the  source  of  the  blood,  it  collects  either  in  the  most  de- 
pendent part  of  the  peritoneum,  or  in  the  pelvic  areolar  tissue  beneath  it. 
Here  it  remains  for  a  time  fluid,  then  undergoes  partial  coagulation,  be- 
coming a  grumous  mass  like  currant  jelly,  and  lastly,  all  the  fluid  being 
absorbed,  a  hard,  resisting  tumor  composed  of  fibrinous  material  remains. 
Should  the  collection  have  occurred  in  the  peritoneum,  its  boundaries  will 
be  the  walls  of  that  cavity  laterally  and  below,  while  a  localized  perito- 
nitis forms  for  it  a  roof  of  effused  lymph.  If  it  collect  in  the  areolar 
tissue  of  the  pelvis,  the  effused  blood  will  make  its  own  nidus  by  perco- 
lating the  loose  structure  and  mechanically  creating  a  space  in  it. 

In  either  of  these  positions  it  is  entirely  absorbed  and  reduced  to  a  hard, 
firm  tumor,  which  remains  for  a  long  time,  or  is  discharged  by  the  vagina 


512  PELVIC    HEMATOCELE. 

or  rectum,  or  into  the  peritoneum.  The  last  point  of  evacuation  is  fortu- 
nately rare.  Nonat1  quotes  Dupuytren  for  the  following  very  ingenious 
and  plausible  explanation  of  the  method  of  such  absorption,  which  he 
likens  to  the  process  of  digestion.  The  vessels  of  the  cyst  which  are  in 
contact  with  the  mass  remove  its  fluid  portion,  and  thus  its  hard  surface 
comes  in  apposition  with  the  sac.  This  excites  effusion  of  serum,  which 
softens  the  fibrinous  wall  and  renders  it  susceptible  of  absorption,  which 
soon  occurs.  Then  again  contact  excites  a  flow  of  fluid,  and  again  this  is 
removed,  until  the  whole  mass  is  diminished  or  completely  absorbed. 

Causes — A  glance  at  the  recognized  causes  of  the  disease  will  make  it 
evident  that  congestion  of  the  pelvic  organs  must,  in  an  eminent  degree, 
predispose  to  it.  This  explains  the  fact  that  it  has  been  found  to  have 
occurred  most  frequently  during  the  period  of  ovarian  activity  and  espe- 
cially during  a  menstrual  epoch. 
The  predisposing  causes  are — 

The  period  of  ovarian  activity,  15  to  45  ; 

Disordered  blood  state,  plethora  or  anaemia ; 

The  menstrual  epoch  ; 

Chronic  uterine  or  ovarian  disease  ; 

The  hemorrhagic  diathesis. 
The  exciting  causes  are — 

Sudden  checking  of  menstrual  How  ; 

Blows  or  falls  ; 

Excessive  or  intemperate  coition  ; 

Obstruction  of  cervical  canal  ; 

Obstruction  of  Fallopian  tubes  ; 

Violent  efforts. 

Varieties There  are   two  forms  of  the  affection,  subperitoneal  and 

peritoneal.  In  the  latter  the  blood  tumor  forms  within  the  peritoneum, 
where  it  in  time  becomes  encysted  unless  death  occur  at  an  early  period. 
In  the  former,  it  occurs  in  the  areolar  tissue  of  the  pelvis,  under  the 
peritoneum. 

The  propriety  of  the  consideration  of  the  former  under  the  same  head 
as  the  latter  has  been  contested  by  Aran,  Bernutz,  and  Voisin,  but  from 
a  clinical  standpoint  it  appears  to  be  quite  valid.  Not  only  have  dis- 
tinct instances  of  subperitoneal  hematocele  been  recorded  by  such  ob- 
servers as  Simpson,  Olshausen,  Tuckwell,  and  Barnes ;  cases  have, 
likewise,  presented  themselves,  which  commencing  as  subperitoneal  ones 
have  ruptured  the  peritoneal  covering  of  the  pelvis,  and  thus  broken  down 
the  theoretical  barrier  which  pathologists  have  been  inclined  to  establish 
between  the  two  varieties. 

Of  the  two  varieties,  the  peritoneal  is  much  the  more  frequent,  at  the 

'  Op.  cit.,  p.  344. 


VARIETIES, 

Fig.  209. 


513 


Peritoneal  hematocele.     (Barnes.) 
Fig.  210. 


Subperitoneal  hematocele.     (Plinmet.) 

same  time  that  it  is  the  more  grave.  In  41  autopsies  Tuckwell  found 'the 
tumor  to  be  peritoneal  in  thirty-eight.  In  a  case  which  I  saw  with  Dr. 
Emmet,  we  were  unable  to  make  a  diagnosis  of  a  tumor  which  lay  ob- 
liquely anterior  to  the  uterus.  In  twenty-four  hours  the  patient  fell  into 
a  state  of  collapse,  and  as  we  saw  her  thus,  the  nature  of  the  tumor,  which 
33 


514  PELVIC    HEMATOCELE. 

we  were  doubtful  about  on  the  previous  day,  became  evident.  Upon  a 
post-mortem  examination  an  ante-uterine  hematocele  as  large  as  a  goose's 
egg  was  found  under  the  peritoneum,  through  which  it  had  broken,  dis- 
charged a  portion  of  its  contents  into  the  peritoneum,  and  caused  collapse 
and  death.  This  is  the  only  ante-uterine,  but  not  the  only  subperitoneal, 
hematocele  with  which  I  have  met. 

Symptoms The  absolute  occurrence  of  hemorrhage  is  generally  pre- 
ceded by  symptoms  which  are  premonitory,  as  fixed,  dull  pain  over  the 
ovaries,  derangement  of  menstruation,  metrorrhagia,  or  prolongation  of 
the  menstrual  discharge.  The  symptoms  of  the  actual  escape  of  blood 
will  depend  in  great  degree  upon  the  nature  and  gravity  of  the  accident 
which  has  given  rise  to  it. 

Sometimes  the  affection  occurs'  without  any  violent  symptoms  and 
almost  without  warning.  It  will  be  appreciated  that  this  would  be  so  if 
it  were  due  to  gradual  reflux  of  blood  on  account  of  constricted  cervix,  or 
transudation,  the  result  of  purpura.  Frequently  a  sudden  manifestation 
of  symptoms  occurs,  and  the  accident  is  announced  as  rapidly  as  is  cere- 
bral apoplexy. 

It  is  evident,  then,  that  the  symptoms  must  differ  widely  in  cases 
marked  by  very  great  and  sudden  loss  of  blood,  and  those  accompanied 
by  very  little.  In  the  first  there  are  evidences  of  profuse  abstraction  of 
vital  fluid,  great  peritoneal  shock,  and  excessive  prostration.  In  the 
second  these  may  all  be  so  slight  as  to  escape  the  notice  of  non-observant 
patients.  The  best  course  which  can  be  pursued  in  reference  to  the  matter 
is,  I  think,  to  take,  as  an  example,  a  case  of  moderate  severity,  and  guard 
the  reader  against  supposing  that  all  attacks  give  the  same  degree  of  in- 
tensity of  symptoms. 

Most  prominent  among  the  symptoms  are — 
Severe  pain  in  the  pelvis; 
Pallor,  faintness,  and  coldness  of  extremities; 
Sense  of  exhaustion; 
Nausea  and  vomiting; 
Metrorrhagia ; 
Uterine  tenesmus; 
Tympanites; 

Interference  with  bladder  and  rectum; 
Small  and  rapid  pulse; 
Depressed  thermometric  range. 
The  patient  feels  as  if  a  large  and  heavy  body  exists  in  the  pelvis,  and 
instinctively  strives  to  expel  it  by  the  vagina.      At  times  the  pain  com- 
plained of  is  very  acute;  at  others,  it  is  a  dull  and  heavy  aching. 

After  a  variable  time,  generally  within  forty-eight  hours,  a  reaction 
from  this  state  of  prostration  occurs.  Sometimes  this  is  slight;  at  others 
decided.     It  is  dependent  chiefly  upon  the  degree  of  inflammation  set  up 


DIFFERENTIATE N  .  5 1  0 

by  the  sanguineous  accumulation  acting  as  a  foreign  body.  This  is  usually 
marked  by  the  following  symptoms  : — 

Tendency  to  chilliness  ; 

Constipation  ; 

Suppression  of  urine  ; 

Great  tympanites  ; 

Heat  of  skin  ; 

High  thermometric  range  ; 

Rapid  pulse  ; 

Tenderness  over  abdomen. 
All  these  symptoms  point  to  two  tacts  :  1st,  sudden  and  excessive  loss 
of  blood  ;  2d,  the  existence  of  some  substance  in  the  pelvis  which  mechan- 
ically interferes  with  its  viscera.  A  part  of  them  might  be  produced  by 
menorrhagia,  a  part  by  sudden  retroversion  ;  but  a  union  of  the  whole 
will  strongly  excite  suspicion  of  hematocele,  and  call  for  a  physical  ex- 
ploration. 

Physical  Signs Vaginal   touch   reveals  a  tumor  usually  posterior  to 

uterus  and  vagina,  and  generally  partially  closing  the  latter.  The  mass 
thus  felt,  if  the  examination  be  made  very  soon  after  its  formation,  will  be 
found  to  be  soft,  smooth,  and  obscurely  fluctuating.  If  a  number  of  days 
have  elapsed  before  it  be  touched,  it  will  give  the  impression  of  a  smooth, 
dense,  solid  body.  The  uterus  will  be  found  pressed  out  of  its  position, 
generally  upwards  and  forwards,  so  that  the  cervix  will  be  above  the  sym- 
physis. Sometimes,  though  rarely,  it  is  forced  out  of  the  median  line  to 
one  side. 

Nonat1  dogmatically  announces  that  the  uterus  is  never  found  between 
the  tumor  and  the  rectum,  that  is  to  say,  behind  the  mass  of  blood;  but 
Chassaignac2  reports  a  case  in  which  the  sanguineous  collection  existed 
entirely  between  the  bladder  and  uterus,  and  consequently  must  have 
forced  that  organ  backwards ;  and  similar  cases  are  recorded  by  G.  Braun, 
Olshausen,  Barnes,  Emmet,  myself,  and  others. 

Rectal  touch  will  show  that  the  bowel  is  partially  closed  by  pressure 
from  the  tumor. 

Abdominal  palpation  will  reveal  the  presence  of  a  hard  mass  which  may 
extend  only  up  to  the  superior  strait,  or  as  high  as  the  navel.  In  cases 
where  a  small  quantity  of  blood  has  been  effused,  and  more  especially 
where  this  has  collected  under  and  not  in  the  peritoneum,  an  abdominal 
tumor  may  not  be  discovered. 

By  the  aid  of  conjoined  manipulation  the  shape,  extent,  and  character 
of  the  mass  may  be  further  ascertained. 

Differentiation The  diseases  with  which  hematocele  may  be  con- 
founded are — 

1  Op.  cit.,  p.  342.  "■  Ccurty,  Mai.  de  l'Uterus,  p.  912. 


516  PELYIC    HEMATOCELE. 

Pelvic  cellulitis  or  abscess  ; 
Retroversion ; 
Extra-uterine  pregnancy ; 
Fibrous  tumor ; 
Dislocated  ovarian  cyst. 
The  mass  created  by  cellulitis  aiid  abscess  is  usually  found  at  the  side 
of  the  uterus,  and  not  posterior  to  that  organ ;  it  develops  less  suddenly 
than  hematocele;  is  hard  at  first,  and  gradually  softens ;  is  exquisitely 
painful  to  touch  ;  does  not  lift  the  uterus  and  press  it  forwards ;  and  is 
not  usually  accompanied  by  metrorrhagia. 

Retroversion  may  present  the  signs  due  to  the  mechanical  results  of 
hematocele,  but  not  those  due  to  loss  of  blood.  If  pregnancy  coexist, 
conjoined  manipulation  will  usually  suffice  for  diagnosis.  If  it  should 
not,  the  uterine  probe  will  elucidate  the  case. 

Extra-uterine  pregnancy  does  not  develop  suddenly,  but  slowly,  and  is 
characterized  by  many  of  the  signs  of  pregnancy.  In  place  of  metror- 
rhagia there  is  usually,  though  not  always,  amenorrhea. 

Fibrous  tumors  grow  slowly,  are  painless,  and  move  with  the  uterus. 
They  are  irregular  and  hard,  and  do  not  usually  push  the  uterus  so  far 
forwards  and  upwards. 

Displaced  ovarian  cysts  are  painless,  show  no  signs  of  hemorrhage,  and 
cause  no  constitutional  disturbance  or  metrorrhagia. 

Course,  Duration,  and  Termination — Hemorrhage  from  the  sources 
enunciated  as  those  of  hematocele  may  be  so  great  as  to  destroy  life  im- 
mediately. Five  such  instances  are  recorded  by  Voisin,  and  Ollivier 
d'Angers1  mentions  two  in  which  death  occurred  in  half  an  hour  from 
rupture  of  a  varicose  utero-ovarian  vein.  Such  a  termination  is,  however, 
decidedly  exceptional.  The  tumor  generally  disappears  by  absorption,  is 
discharged  by  the  rectum  or  vagina,  or  remains  a  hard,  indurated  mass 
long  afterwards.  Discharge  is  most  frequently  followed  by  recovery,  but 
sometimes  putrefaction  occurs  in  the  walls  of  the  sac,  septica>mia  takes 
place,  and  death  ensues.  The  process  of  absorption  may  be  accomplished 
in  three  weeks,  or  six  months  may  elapse  before  it  is  complete. 

In  some  cases  a  slow  and  steady  hemorrhage  appears  to  go  on  for  weeks, 
and  render  the  bloody  tumor  gradually  larger.  In  others  hemorrhages 
subsequent  to  the  first  take  place  after  this  has  become  encapsulated. 
After  subsidence  of  the  symptoms  of  reaction,  chill,  fever,  and  sweating 
often  come  on  late,  marking  suppuration  in  the  mass,  and  slight  septic 
absorption. 

Prognosis — The  prognosis  of  hematocele  must  be  governed  in  great 
degree  by  the  amount  of  blood  lost,  the  degree  of  constitutional  shock 
resulting,  and  the  intensity  of  reaction  excited.     As  a  rule  it  is  favorable  ; 

1  Noeggerath,  Bui.  N.  Y.  Acad.  Med.,  vol.  i.  p.  577. 


TREATMENT.  517 

especially  so,  I  should  say,  when   treated    upon   the  expectant   plan,  and 
not  by  immediate  surgical  interference. 

In  cases  of  peritoneal  form  a  graver  prognosis  is  called  for  than  in  tin; 
subperitoneal,  for  evident  reasons  ;  and  when:  a  gnat  deal  of  blood  lias 
been  lost  the  dangers  are  greater  than  where  the  amount  has  been  more 
limited.  This  is  true  not  only  from  the  fact  that  an  excessive  flow  might 
cause  death  from  exhaustion,  but  because  the  removal  of  so  large  an 
amount  of  coagulum,  whether  by  absorption  or  discharge,  must  necessarily 
expose  the  patient  to  great  dangers. 

AVhen  death  occurs  it  is  usually  a  consequence  of  loss  of  blood,  shock 
from  sudden  invasion  of  the  peritoneum,  peritonitis,  rupture  of  the  encap- 
sulated mass  into  the  peritoneum,  or  septicaemia. 

Treatment The  physician  will  rarely  be  called  upon  to  resort  to  treat- 
ment before  the  amount  of  blood  which  is  destined  to  be  lost  has  collected 
in  the  pelvis.  He  will,  however, -often  be  present  to  witness  the  great 
constitutional  disturbance  and  excessive  prostration  and  pain  which  imme- 
diately follow  the  hemorrhage.  The  diagnosis  being  made,  the  indica- 
tions for  treatment  will  be  simple  enough  : — 

1st.  To  check  tendency  to  further  loss  ; 
2d.  To  prevent  death  from  prostration  ; 
3d.  To  relieve  pain. 

These  indications  should,  as  far  as  possible,  be  met  simultaneously,  for 
the  dangers  to  be  combated  all  occur  at  one  and  the  same  moment.  The 
patient  should  at  once,  without  the  delay  attendant  upon  changing  the 
clothing,  etc.,  be  put  in  a  condition  of  perfect  rest,  and  a  full  dose  of 
morphia  be  administered  hypodermically.  A  bladder  of  crushed  ice  or 
cloths  wrung  out  of  iced  water  should  be  laid  over  the  hypogastrium,  and 
bottles  of  hot  water  or  warm  bricks  wrapped  in  flannel  should  be  put  to 
the  soles  of  the  feet.  Should  the  stomach  not  be  very  irritable,  brandy 
and  water  or  iced  champagne  should  be  given  freely  by  the  mouth. 

If  prostration  be  so  alarming  as  to  threaten  collapse,  and  the  stomach 
be  intolerant  of  ingesta,  brandy  or  sulphuric  ether  in  doses,  the  former  of 
two  drachms,  and  the  latter  of  half  a  drachm,  should  be  injected  subcuta- 
neously  by  the  hypodermic  syringe. 

Reaction  having  taken  place,  the  most  perfect  quietude  should  be  ob- 
served, pain  should  be  relieved  and  nervous  shock  prevented  by  the  free 
use  of  opium  or  one  of  its  salts,  and  the  diet  should  consist  of  milk,  animal 
broths,  and  gruels  of  farina,  sago,  or  indian  meal. 

And  now  will  arise  the  important  question,  whether  the  accumulated 
blood  should  be  left  for  removal  by  nature,  or  should  be  evacuated  by 
surgical  means.  Recamier,  in  introducing  the  subject  to  the  profession, 
inaugurated  the  practice  of  evacuating  such  tumors,  and  Nelaton  indorsed 
and  popularized  it.  But  experience  taught  Xelaton  that  the  procedure 
was  not  judicious,  and  "to-day  he   proscribes  it  in  an  almost  absolute 


518  PELVIC    HEMATOCELE. 

manner."'  Immediate  surgical  interference  presses  its  claims  in  consider- 
ation of  the  facts  that — 

1st.   It  is  capable  of  cutting  short  a  lengthy  and  dangerous  disorder; 

2d.  It  may  save  the  patient  from  the  dangers  incident  to  absorption  as 
well  as  discharge. 

3d.  It  removes  from  the  peritoneum  or  pelvic  cellular  tissue  a  foreign 
body,  which,  undisturbed,  would  prove  the  focus  of  inflammation. 

It  is  not  surprising  that  it  was  the  favorite  plan  in  the  infancy  of  the 
subject.  When,  however,  pathologists  had  had  an  opportunity  of  study- 
ing the  natural  history  of  the  affection,  it  was  as  naturally  abandoned,  for 
the  following  reasons : — 

1st.  It  was  discovered  that,  when  not  interfered  with,  hematocele  very 
generally  passes  away  rapidly. 

2d.  It  was  discovered  that  the  dangers  of  puncture  were  greater  than 
those  of  the  tumor  left  undisturbed  ; 

3d.  Medical  means  were  found  to  exert  a  marked  controlling  influence 
over  its  complications. 

With  the  light  which  experience  has  thrown  upon  this  point,  it  appears 
to  me  that,  without  being  dogmatic,  we  may  safely  adopt  this  rule.  The 
mere  presence  of  a  large  amount  of  blood  in  the  peritoneum  does  not 
warrant  evacuation.  If,  as  time  passes,  suppuration  within  the  sac,  which 
has  then  pretty  certainly  become  encapsulated,  and  septic  absorption  are 
manifested  by  chills,  febrile  action,  and  profuse  sweating,  the  softening  mass 
should  be  discharged  by  incision.  In  other  words,  so  long  as  the  accumu- 
lated blood  appears  to  be  doing  no  decided  harm  and  nature  seems  to  be 
causing  its  absorption,  it  should  be  left  alone.  But  so  soon  as  evidences 
of  septicaemia  are  observed,  it  should  be  evacuated.  Under  these  circum- 
stances, a  neglect  of  surgical  interference  would  be  culpable.  Without 
such  indications  it  should  be  avoided,  and  reliance  placed  upon  medical 
resources,  for  it  should  be  borne  in  mind  that  the  collection  of  blood  is 
usually  in  the  peritoneum,  and  that  incision  of  this  membrane,  in  addition 
to  its  own  inherent  dangers,  would  always  expose  to  those  arising  from 
admission  of  air. 

Methods  of  Operating The  patient  being  placed  upon  the  back,  as  if 

for  lithotomy,  a  trocar  and  canula  may  be  held  in  the  right  hand,  guided 
to  the  most  fluctuating  and  dependent  part  of  the  mass,  and  plunged  in. 
Or,  the  patient  lying  on  the  left  side,  the  perineum  and  posterior  vaginal 
wall  may  be  lifted  by  Sims's  speculum,  and  an  incision  made  into  the  wall 
of  the  tumor  by  a  tenotomy  knife  or  small  bistoury.  Through  the  open- 
ing thus  made,  one  or  two  fingers  should  be  introduced  and  the  clots  re- 
moved. After  evacuation  by  either  method,  the  nozzle  of  a  syringe  should 
be  introduced  into  the  sac,  and  a  stream  of  tepid  water,  or  of  this  with  a 

•  Nouat,  op.  cit 


FIBROID    TUMORS    OF    THE    UTERUS.  519 

very  small  amount  of  carbolic  acid,  should  l>o  very  gently  and  cautiously 
made  to  wash  out  the  cavity  remaining.  This  should  be  repeated  once  or 
twice  in  twenty-four  hours,  for  prevention  of  septicaemia.  All  this  should, 
as  far  as  possible,  be  done  under  the  antiseptic  method. 

After  the  abatement  of  acute  symptoms,  a  blister,  four  by  six  inches, 
should,  unless  some  contra-indication  exists,  be  applied  over  the  hypo- 
gastrium,  and  this  may  with  advantage  be  repeated  every  ten  or  twelve 
days.  Its  results  will  often  be  very  marked,  and,  although  apparently 
harsh  practice,  it  prevents  much  suffering,  while  it  causes  but  little. 

As  time  passes  and  pain  is  relieved,  quinine,  alone  or  combined  with 
sulphuric  acid,  in  full  doses  will  prove  a  valuable  remedy,  and  should  be 
kept  up  perseveringly. 


CHAPTER    XXXIV. 

MYO-FIBROMATA  OR  FIBROID  TUMORS  OF  THE  UTERUS. 

Definition  and  Synonyms The  parenchyma  of  the  uterus  is  liable  to 

undergo  a  localized  hypertrophy,  which  results  in  the  production  of  two 
varieties  of  tumors ;  the  fibrous  and  the  fibro-cystic.  The  first,  which  is 
one  of  the  most  frequent  pathological  conditions  to  which  this  organ  is 
subject,  will  now  receive  attention,  while  the  second  and  much  rarer  form 
will  be  treated  of  in  a  separate  section. 

By  the  older  writers  fibrous  tumors  were  styled  tubercula,  steatomata, 
sarcomata,  etc.  Since  their  true  nature  has  been  more  carefully  studied 
by  aid  of  the  microscope  and  been  understood,  they  have  been  described 
under  the  names  of  fibrous  tumors,  uterine  fibroids,  fibroma,  and  more 
recently,  by  Virchow,  myoma.  I  have  adopted  the  terms  which  head 
this  chapter,  following  the  example  of  Billroth  for  the  first,  and  of  Klob 
for  the  second,  for  the  reason  that  neither  that  of  fibroma  nor  myoma 
alone  expresses  the  existing  pathological  condition.  Billroth1  rejects  the 
latter  name,  which  signifies  that  these  growths  consist  in  hypertrophy  of 
muscular  substance  ;  and  at  the  same  time  he  refuses  to  admit  the  former, 
as  that  conveys  the  equally  incorrect  idea  that  they  are  constructed  of 
connective  tissue.  Fibroid  (fibrosus  and  *i§o$),  resembling  fibrous  tissue, 
is  at  least  not  calculated  to  mislead,  while  myo-fibroma  expresses  the 
exact  truth. 

History — Until  the  time  of  Dr.  William  Hunter,  who  wrote  towards 
the  close  of  the  eighteenth  century,  the  true  nature  of  uterine  fibroids  was 

1  Surg.  Pathol.,  p.  583. 


520  FIBROID    TUMORS    OF    THE    UTERUS. 

not  appreciated.  They  were  confounded  with  malignant  growths,  of  which 
they  were  regarded  as  a  variety.  He  described  them  under  the  name  of 
fleshy  tubercle,  and  contributed  greatly  to  the  knowledge  of  their  patho- 
logy; but  it  was  not  until  the  writings  of  Chambon,1  Baillie,  Bayle,  and 
others  that  the  subject  was  fully  elucidated.  Sir  Charles  Clark,  in  1814, 
wrote  an  excellent  chapter  upon  them,  which  would  almost  answer  the 
requirements  of  our  day. 

Pathology — Surprise  that  any  confusion  should  have  existed  between 
these  tumors  and  cancerous  growths,  will  cease  when  we  consider  that 
their  identity  is  boldly  assumed  by  so  careful  an  observer  as  Dr.  Ashwell, 
as  late  as  1844.  He  gives  five  reasons  for  his  belief,  which  he  declares 
appear  to  him  "  conclusive."  His  reasoning  has  failed  to  convince  others, 
no  writer  since  his  time  having  adopted  the  view  which  Dr.  Hunter  suc- 
ceeded in  abolishing,  and  no  fact  in  gynecology  is  now  more  fully  settled 
than  that  of  the  non-malignancy  of  these  tumors. 

Until  recently  the  question  has  not  been  settled  as  to  the  possibility  of 
their  undergoing  cancerous  degeneration.  Bayle  and  Lobstein  have  de- 
clared that  they  never  do  so,  and  the  researches  of  Cruveilhier  and  Lebert 
tend  to  support  the  view  ;  while  Kiwisch,  Dupuytren,  Atlee,'2and  Simpson 
believe  that  malignant  degeneration  occurs  in  rare  cases.  The  weighty 
authority  of  Virchow3  is  cast  into  the  scale  favoring  the  possibility  of  both 
carcinomatous  and  sarcomatous  degeneration,  and  Klob  agrees  in  this 
assertion.  "  In  1862,"  says  the  latter  author,  "a  singular  specimen  was 
added  to  the  Salzburg  Museum.  From  a  fibroid  tumor  the  size  of  a  child's 
head,  situated  in  the  posterior  walls  of  the  uterus,  carcinoma  had  un- 
doubtedly been  developed  without  any  other  portion  of  the  body  being 
affected,  and  I  am  therefore  constrained  to  allow  the  possibility  of  such  a 
transition,  although  I  cannot  recall  a  second  case  of  this  kind  either  in 
the  literature  of  the  subject  or  in  my  rather  extensive  experience." 

Although  this  case  seems  to  settle  the  matter  of  possibility,  at  least,  it 
must  not  be  forgotten  that  beyond  doubt  such  a  change  of  type  is  exceed- 
ingly rare.  It  is  in  this  connection  a  fact  worthy  of  note  that  in  the  ne- 
gress,  in  whom  fibroid  tumors  are  so  common  as  to  be  regarded  by  some 
as  almost  universally  met  with  after  the  thirtieth  year,  carcinomatous 
affections  of  the  uterus  are  very  rarely  seen. 

I  have  met  with  two  cases  in  which  uterine  fibroids  which  had  been 
known  to  exist  for  eight  and  ten  years,  and  had  behaved  like  benign  growths, 
suddenly  took  upon  themselves  the  aspect  of  sarcoma,  and  led  to  a  fatal 
termination.  In  one  case  the  tumor  was  removed  post-mortem,  and  in  the 
other  ante-mortem  with  great  relief  to  symptoms. 

1  Mai.  <lc  lTterus.  *  McClintock,  Diseases  of  Women. 

3  Pathologic  des  Tuuieurs,  Paris,  1671. 


PATHOLOGY.  .521 

Uterine  fibroids  may  develop  singly,  when  ordinarily  they  do  not  attain 
to  a  very  great  size.  Sometimes,  however,  they  exist  in  great  numbers, 
and  grow  to  a  very  large  size.  Courty  reports  one  weighing  fifty  pounds, 
and  I  have  removed  one,  with  uterus  and  both  ovaries,  of  the  same  weight. 
Some  years  ago  I  exhibited  to  the  New  York  Pathological  Society,  the 
uterus  of  a  negress  which  contained  thirty-five  tumors  of  every  size  between 
that  of  a  foetal  head  and  that  of  a  marble. 

Fibroids  may  develop  in  any  part  of  the  uterus ;  but  the  usual  site  is  in 
the  body  or  fundus.  Mr.  S.  Lee  examined  seventy-four  preparations  in 
the  London  museums,  and  found  that  the  rarest  of  all  locations  for  them  is 
the  cervix.  A  very  interesting  instance  of  a  large  tumor  developed  below 
the  os  internum  is  reported  by  Dr.  Murray,  in  the  sixth  volume  of  the 
London  Obstetrical  Transactions.  I  have  myself  removed  several  of  this 
character  from  the  parenchyma  of  the  cervix,  the  body  of  the  uterus  being 
in  no  wise  involved. 

Their  structure  varies  very  greatly,  not  only  from  their  original  develop- 
ment being  different,  but  from  their  being  susceptible  of  several  diseased 
states,  which  will  very  soon  be  mentioned,  and  which  produce  their  cha- 
racteristic alterations.  The  typical  form  is  that  of  hard,  resisting  fibrous 
tissue,  which  creaks  under  the  knife.  Under  the  microscope  this  is  found 
to  consist  of  long,  fine  fibres,  generally  united  in  bundles ;  of  fusiform 
fibre-cells  analogous  to  fibro-plastic  elements  ;  and  of  round  or  elliptic 
granules  of  small  size  ;  the  whole  being  bound  together  by  fine  intercellular 
substance. 

They  consist  of  the  hypertrophied  elements  of  the  uterus,  to  which 
organ  they  are  strictly  homologous.  In  the  majority  of  cases,  it  is  de- 
clared by  recent  pathological  investigators,  that  connective  tissue  pre- 
ponderates in  their  construction,  but  there  is  always  a  certain  degree  of 
muscular  hypertrophy  concerned  in  their  development ;  hence  Billroth's 
objection  to  the  terms  fibroma  and  myoma.  In  some  cases  the  amount  of 
muscular  exceeds  that  of  connective  tissue  in  their  construction.  This, 
which  may  be  styled  the  normal  type  of  the  uterine  fibroid,  is  departed 
from  by  formation  of  cysts  in  the  midst  of  the  fibrous  tissue,  which  consti- 
tutes the  tumor  one  of  fibro-cystic  character. 

Uterine  fibroids  are  liable  to  a  variety  of  diseases,  among  which  the 
most  frequent  are  oedema ;  inflammation  ;  gangrene  ;  fatty,  colloid,  and 
calcareous  degeneration ;  and  apoplexy.  The  last  consists  in  rupture  of 
small  bloodvessels  within  the  mass,  and  consequent  accumulation  of  blood. 

Very  rarely  the  wdiole  mass  becomes  a  ball  of  calcareous  matter,  which, 
projecting  in  utero  and  becoming  detached^  is  sometimes  discharged  per 
vaginam.  This  is  the  disease  which  was  described  by  old  writers  as  ute- 
rine calculus.  The  uterine  attachment  of  fibroids  of  compound  character 
is  sometimes  the  seat  of  a  species  of  varicose  degeneration  of  the  small 


522 


FIBROID    TUMORS    OF    THE    UTERUS. 


vessels,  which  causes  the  structure  to  resemble  erectile  tissue.  Tumors 
thus  affected  have  been  styled  by  Virchow,  telangiectatic  tumors.  This  vas- 
cular structure  readily  bleeds,  and  in  one  case  I  saw  it  the  cause  of  a  small 


Uterine  fibroma.    Oblique  longitudinal  section  of  muscular  cell-bundles.     (Billroth.) 


hematocele.  But  large  vessels  are  likewise  discovered  in  the  pedicles  of 
fibroids ;  Caillard  reporting  one  the  size  of  the  radial  artery.  Klob  has 
met  with  but  one  such  vessel,  which  was  the  size  of  the  uterine  artery. 

Varieties. — Klob  divides  these  growths  into  two  classes — simple  and 
compound.  The  first  consists  of  one  tumor,  which  is  generally  spherical, 
and  which  is  connected  by  loose  connective  tissue  with  the  uterus.  The 
second  is  a  compound  tumor,  made  up  of  a  number  of  small  fibroids,  con- 
nected by  loose  connective  tissue.  The  second  variety  is  more  vascular 
than  the  first,  and  its  surface  is  nodulated  and  not  smooth.  Both  these 
classes  present  themselves  clinically  in  three  varieties,  which  are  created 
by  the  locality  of  the  growths  in  the  walls  of  the  uterus.  If  they  lie 
under  the  mucous  membrane  projecting  into  the  uterus,  they  are  called 
submucous ;  if  under  the  peritoneum,  subserous ;  if  in  the  wall  of  the 
uterus,  interstitial. 

If  a  tumor  be  situated  in  the  wall  of  the  uterus,  it  may  remain  there 
until  it  assumes  large  dimensions.  Should  it  be  near  the  mucous  or  serous 
lining,  it  is  subjected  to  contractile  efforts  on  the  part  of  the  surrounding 
parenchyma,  which  are  excited  by  its  presence,  and  which  often  in  time 
force  it  towards  the  uterine  or  abdominal  cavity.     Sometimes  its  connec- 


CAUSES COMPLICATIONS.  f>23 

Mon  with  the  mother  tissue  is  kept  up  by  a  broad  base;  s"mctimes  it  is 
limited  to  a  long,  slender  pedicle,  which,  in  the  case  of  the  subperitoneal 
varieties,  allows  of  great  mobility.  Should  the  mass  be  forced  into  tin; 
uterine  cavity,  and  gradually  assume  a  slender,  pedunclated  attachment, 
it  receives  the  name  of  fibrous  polypus,  which  is  therefore  a  variety  of 
submucous  fibroid. 

These  neoplasms  often  affect  the  uterus  very  curiously.  The  interstitial 
varieties  produce  every  form  of  displacement ;  the  sub-mucous  sometimes 
produce  complete  inversion  of  uterus  and  vagina ;  and  the  sub-peritoneal, 
Virchow  declares,  by  dragging  the  fundus  upwards  not  only  draw  out 
1  he  cervix  so  as  to  make  it  resemble  the  urethra,  but  absolutely  cause 
"  the  spontaneous  separation  of  the  neck  from  the  body  of  the  uterus." 
The  last  variety,  too,  sometimes  shows  most  singular  migrations.  The 
pedicle  being  broken,  they  have  at  times  been  found  rolling  about  freely 
in  the  peritoneum,  and  at  others,  having  set  up  adhesive  inflammation, 
they  have  been  found  detached  from  the  uterus,  and  attached  to  some 
other  abdominal  viscus. 

Causes — The  predisposing  causes,  or  rather  those  generally  regarded 
as  such,  are — 

Race,  the  African  being  peculiarly  liable  ; 

Age,  from  thirty  to  forty-five  ; 

Nulliparity ; 

Menstrual  disorders  of  long  standing. 
Concerning  the  exciting  causes,  one  writing  in   the  year  1874  may, 
unfortunately,  quote  the  words  of  Sir  Charles  Clarke,  recorded  in  1814: 
"  Nothing  is  known  respecting  the  cause  of  this  disease."     Sixty  years  of 
research  have  thrown  no  light  upon  its  etiology. 

Complications. — The  most  frequent  of  the  complications  which  show 
themselves  in  the  course  of  the  disease  are — 

Endometritis ; 

Displacement ; 

Cystitis ; 

Obstruction  of  the  rectum  ; 

Hemorrhoids  ; 

Pelvic  peritonitis ; 

Areolar  hyperplasia ; 

Atrophy  of  uterine  walls  ; 

Grave  menstrual  disorders. 
Every  one  who  has  made  autopsies  upon  cases,  in  which  uterine  fibroids 
have  existed,  must  have  been  struck  by  the  fact  of  the  varied  appearance 
of  the  walls  of  the  uterus.  "Where  several  tumors  exist  the  uterine  cavity 
is  sometimes  so  perverted  and  rendered  so  tortuous  that  it  cannot  be 
traced,  while  in  cases  where  a  large  number  of  tumors  are  formed,  the 


524  FIBROID    TUMORS    OF    THE    UTERUS. 

whole  uterus  seems  to  have  disappeared,  its  place  being  usurped  by  tumors. 
In  the  case  already  cited,  in  which  I  counted  thirty-five  tumors,  no  trace 
of  the  uterus  could  be  discovered  by  the  naked  eye,  above  the  os  internum. 
In  some  cases  the  vice  of  nutrition  set  up  by  the  presence  of  these  growths 
results  in  thickening  of  the  uterine  walls  by  the  establishment  of  inter- 
stitial hypertrophy,  in  others  localized  points  of  thickening  exist,  while  in 
others  still  the  wall  of  the  uterus  may  become  so  attenuated  by  distention 
and  atrophy  as  to  leave  only  a  thin  film  to  represent  it.  This  distended 
and  attenuated  organ  is  that  which  "Walter  has  styled  the  "membranous 
uterus." 

Symptoms. —  The  enumeration  of  complications  just  given  is  a  sufficient 
explanation  of  the  great  number  of  rational  signs  which  present  them- 
selves, for  not  only  do  we  meet  with  the  symptoms  of  fibroid  tumors,  but 
with  those  of  a  variety  of  disorders  which  they  excite.  Most  prominent 
among  the  symptoms  are — 

Menorrhagia  or  metrorrhagia ; 
Irritability  of  bladder  and  rectum  ; 
Pain  throughout  the  pelvis  ; 
Uterine  tenesmus ; 
Profuse  leucorrhoea ; 
Dysmenorrhea ; 

Signs  of  pressure  on  crural  nerves  and  vessels ; 
Watery  discharge  from  uterus. 
These  symptoms  are  not  equally  common  to  the  three  varieties  of  the 
affection.      Subperitoneal  tumors  often,  and  interstitial  tumors  sometimes, 
are  accompanied  by  none,  or  at  least  by  very  few.  of  them.     It  is  the 
submucous  variety  which  most  constantly  and  prominently  develops  them. 
The  immediate  effects  of  uterine  fibroids  are  exerted  upon  the  system 
through  the  following  means  : — 

1st.  They  produce  excessive  menstrual  discharge  and  profuse  leucor- 
rhoea, which  impoverish  the  blood. 

2d.   They  press  upon  and  derange  the  innervation  of  neighboring  parts. 
3d.  They,  in  some  way,  interfere  with  hematosis  and  the  functions  of 
the  ganglionic  nervous  system. 

4th.  They  disorder  the  mind  by  creation  of  depression  of  spirits,  from 
the  fact  that  the  patient  recurs  with  gloomy  apprehension  to  their  exist- 
ence almost  constantly. 

Physical  Signs Although    the   rational    signs  are  so  numerous  and 

striking,  they  can  never  do  more  than  excite  a  suspicion,  which  leads  to 
investigation  by  physical  means. 

In  the  case  of  a  large  tumor  no  difficulty  in  diagnosis  will  present  itself; 
for  the  result:  of  vaginal  touch,  abdominal  palpation,  and  conjoined  ma- 
nipulation wiH  be  so  decided  as  to  settle  the  character  of  the  case  defini- 


DIFFERENTIATION.  525 

tively.  When,  however,  :i  growth  of  small  size  exists,  great  difficulties 
will  often  attend  diagnosis,  which  may  be  delayed  until  the  case  has  been 
under  observation  for  a  long  time.  A  thorough  examination  involves  lull 
and  careful  exploration,  by  touch,  of  the  anterior  and  posterior  surfaces  of 
the, uterus,  as  well  as  of  its  cavity  to  the  fundus. 

To  examine  the  external  surfaces  of  the  uterus,  the  patient  should  lie 
upon  the  back  with  the  thighs  flexed.  All  constriction  should  be  removed 
from  the  waist,  and  the  bladder  and  rectum  emptied.  The  examiner  then, 
depressing  the  uterus  by  the  right  hand  placed  over  the  hypogastrium, 
should  sweep  the  index  finger  of  the  other  as  high  up  as  possible  over  the 
posterior  wall,  first  by  vaginal  and  then  by  rectal  touch.  While  the  finger 
in  the  vagina  or  rectum  lifts  the  uterus,  the  tips  of  the  fingers  placed  on 
the  abdomen  should  be  forced  behind  the  fundus,  and  downwards  over  the 
posterior  uterine  wall  so  as  to  approach  the  finger  within  the  pelvis.  By 
these  means  the  posterior  wall  will  be  superficially  examined  in  women 
with  tense  abdominal  muscles,  thoroughly  in  those  in  whom  they  are  thin 
and  relaxed. 

The  finger  in  the  vagina  now  drawing  the  cervix  forwards,  the  fingers 
of  the  hand  on  the  abdomen  should  be  made  to  depress  its  walls  so  as  to 
sweep  from  the  fundus  over  the  anterior  surface  down  to  the  cervix.  The 
finger  under  the  cervix  lifting  it  up  will  offer  itself  as  an  opposing  force  to 
the  hand  on  the  abdomen.  This  manoeuvre  will  fully  expose  to  examina- 
tion the  anterior  surface  of  the  uterus,  unless  the  patient  be  very  fat. 
Should  she  be  so,  a  tenaculum  may  be  fastened  in  the  cervix,  and  the  ute- 
rus drawn  down  by  it,  so  that  the  posterior  wall  will  be  better  within  reach 
of  rectal  touch,  and  the  anterior  wall  within  that  of  vaginal  exploration 
when  the  finger  is  pressed  firmly  against  the  base  of  the  bladder. 

When,  in  a  case  in  which  it  is  of  importance  that  a  certain  diagnosis 
should  be  arrived  at,  it  proves  impossible  to  do  so  by  use  of  the  means 
thus  far  mentioned,  the  modification  of  Simon's  method,  mentioned  in  the 
chapter  upon  Diagnosis,  may  be  resorted  to  with  great  confidence  as  to  the 
results  which  it  will  yield. 

For  investigating  the  interior  surface  of  the  uterus,  the  neck  should  be 
fully  dilated  by  tents,  and  immediately  upon  their  removal,  the  uterus 
being  depressed  as  for  examination  of  the  outer  surface,  the  finger  should 
be  carried  into  the  cavity  of  the  body. 

Differentiation The  diseases  which  may  be  confounded  with  fibrous 

tumors  are — 

Pregnancy  ; 

Periuterine  cellulitis  or  abscess  ; 

Pelvic  hematocele  ; 

Anteflexion  or  retroflexion  ; 

Ovarian  tumors  ; 

Fecal  impaction. 


526  FIBROID    TUMORS    OF    THE    UTERUS. 

In  pregnancy,  amenorrhea  and  other  signs  of  utero-gestation  exist, 
while  in  uterine  fibroids  there  is  usually  a  tendency  to  menorrhagia.  In 
pregnancy  the  uterus  is  symmetrical,  in  fibroids  usually  asymmetrical.  The 
tumor  found  in  pregnancy  is  generally  softer  than  in  fibroids,  and  more 
uniformly  median  in  position.  In  a  doubtful  case  time,  with  its  develop- 
ment of  foetal  movements,  will  always  settle  the  point. 

The  tumor  created  by  cellulitis  is  usually  immovable,  very  sensitive, 
accompanied  by  fever,  comes  on  suddenly,  and  fixes  the  uterus.  A  fibroid 
tumor  is  the  opposite  of  this  in  every  respect. 

Hematocele  generally  occurs  suddenly  and  with  violent  symptoms.  The 
tumor  is  sensitive  and  immovable,  at  first  semi-fluid,  and  accompanied  by 
tympanites  and  constitutional  disturbance.  Fibroid  tumors  show  no  such 
symptoms. 

Flexion  may  be  determined  by  the  uterine  probe,  and  differentiation 
established  between  it  and  fibroids  by  conjoined  manipulation  and  rectal 
touch. 

Ovarian  tumors  of  solid  form  are  the  only  ones  which  usually  give  diffi- 
culty in  diagnosis,  and  these  are  rare.  They  are  unaccompanied  by  me- 
norrhagia, can  be  pushed  from  side  to  side  without  affecting  the  position 
of  the  uterus  as  ascertained  by  vaginal  touch,  and  are  less  affected  by 
movement  of  the  uterus  by  means  of  the  uterine  sound.  In  cases  where 
an  ovarian  tumor  is  firmly  attached  to  the  uterus,  differentiation  is  not 
only  difficult,  but  often  impossible. 

Fecal  impaction  presents  a  tumor  which  can  often  be  indented  by  pres- 
sure, is  generally  in  the  caput  coli,  does  not  move  with  the  uterus,  gives 
severe  intestinal  pain  and  disorder,  and  exerts  little  influence  on  the  func- 
tions of  the  uterus. 

From  this  rapid  disposal  of  the  subject  of  differentiation  it  must  not  be 
supposed  that  it  is  always  an  easy  matter.  In  many  cases  only  careful 
watching  will  enable  the  diagnostician  to  arrive  at  a  certain  conclusion. 

Prognosis The   practitioner  cannot  be  too  cautious  or  display   too 

much  reticence  in  pronouncing  the  prognosis  of  uterine  fibroids.  There 
are  few  diseases  in  which  the  young  physician  will  be  led  into  greater  error 
or  be  made  to  regret  more  decidedly  an  over-confident  prediction.  Fibroid 
tumors,  unless  of  great  size,  rarely  <*nd  fatally,  however  gloomy  the  pros- 
pect may  appear  when  they  are  first  discovered.  And  yet  death  from 
them  is  not  so  infrequent  as  to  warrant  an  entirely  favorable  prognosis. 

Frequency These  statements  are  to  a  certain  degree  corroborated  by 

an  examination  into  their  frequency.  Were  they  as  dangerous  as  is  some- 
times supposed,  a  large  number  of  deaths  would  be  annually  produced  by 
them,  for,  to  use  the  words  of  McClintock,  *'  without  question  the  most 
frequent  organic  disease  of  the  uterus,  if  we  except  inflammation  and  its 
effect.-,  is  fibrous  tumor."     Bayle  estimated  that  of  all  women  dying  be- 


COURSE,    DURATION,    AND    TERMINATION.  ")27 

yoml  thirty-five  years  of  age,  twenty  per  cent,  were  thus  affected.  Even 
supposing  that  this  assumption  was  an  exaggerated  one,  an  idea  of  the 
frequency  of  the  affection  may  be  gathered  from  the  fact  of  his  venturing 
upon  it,  and  surprise  at  it  will  be  modified  when  the  following  extract  is 
read  from  Klob.1  In  speaking  of  their  frequency,  he  says,  "At  the  cli- 
macteric period,  it  is  such  that  undoubtedly  40  per  cent,  of  the  uteri  of 
females,  who  die  after  the  fiftieth  year,  contain  fibroid  tumors." 

Let  the  diagnostician  who  has  discovered  a  uterine  fibroid,  and  feels 
prompted  to  give  a  grave  prognosis  concerning  it,  bear  these  facts  in  mind, 
and  he  may  be  prevented  from  injuring  his  patient's  comfort  and  his  own 
reputation  by  so  doing. 

Course,  Duration,  and  Termination. — As  already  stated,  these  growths 
may  attain  the  enormous  weight  of  fifty  pounds.  Fortunately  they  very 
rarely  reach  such  dimensions,  but  even  when  they  do  not,  they  sometimes 
exhaust  the  patient  by  metrorrhagia,  leucorrhoca,  hydrorrhoea,  and  a  low 
grade  of  constitutional  irritation,  often  attended  by  hectic  fever.  But  this 
termination,  like  the  preceding,  is  exceptional.  Having  attained  a  mode- 
rate size  they  generally  remain  stationary,  or  increase  slowly  Until  the 
menopause,  creating  considerable  inconvenience  and  depreciating  the 
patient's  strength  by  hemorrhage.  Then  undergoing  a  certain  degree  of 
atrophy  with  the  cessation  of  uterine  and  ovarian  functions,  they  cease 
to  be,  to  any  degree,  a  source  of  annoyance,  or  at  least  of  danger.  Even 
during  the  age  of  uterine  activity,  nature  may,  unaided,  effect  a  cure  by 
the  following  means  : — 

Absorption  or  atrophy ; 

Direct  expulsion  by  rupture  of  attachment ; 

Sloughing,  from  deprivation  of  nutrition,  or  inflammation  ; 

Calcareous  degeneration  ; 

Gangrene. 
The  tumor  is  sometimes  deprived  of  nutrition  by  inflammatory  action 
occurring  in  the  vascular  structure  of  the  uterine  attachment,  which  has 
already  been  described,  collections  of  pus  being  sometimes  discovered  in  it. 
Throughout  their  existence  these  tumors  sympathize  in  the  uterine 
changes  which  attend  upon  these  three  conditions:  menstruation,  utero- 
gestation,  and  the  menopause.  With  the  occurrence  of  menstruation  they, 
like  the  tissue  of  the  uterus,  become  congested,  enlarged,  and  sensitive. 
During  pregnancy  their  component  muscular  fibres  grow,  and  probably 
undergo  retrograde  metamorphosis  after  delivery.  As  senile  atrophy  suc- 
ceeds the  menopause,  their  nutrition  is  impaired,  and  fatty  and  calcareous 
degeneration  sometimes  occur. 

Sometimes  fluid  collections  take  place  within  these  masses,  some  morbid 
process  destroying  their  tissue  as  if  by  liquefaction.      The  fluid  thus  col- 

'  Op.  cit.,  p.  177. 


528  FIBROID    TUMORS    OF    THE    UTERUS. 

lecting  may  be  purulent,  watery,  or  sanguineous.  In  some  cases  a  colloid 
degeneration  is  said  by  pathologists  to  occur  in  or  near  the  centre  of  the 
mass,  which  softens  down  and  liquefies  the  fibroid  tissue.  In  others, 
an  apoplexy  takes  place,  which  creates  the  initial  cavity,  and  this  is 
subsequently  found  filled  with  the  debris  of  the  clot  and  with  turbid 
serum. 

Palliative  Treatment In  the  vast  majority  of  cases  of  interstitial  and 

subserous  fibroids,  the  efforts  of  the  practitioner  should  be  limited  to  pallia- 
tion of  the  evils  resulting  from  these  growths.  These  evils  will  generally 
be  due  to  either  one  or  all  of  the  three  following  conditions  which  result 
from  them  :  displacement  of  the  uterus  ;  pressure  on  surrounding  organs 
and  parts ;  and  menorrhagia  or  metrorrhagia.  The  first  will  often  be  greatly 
relieved  by  restitution  of  the  displaced  organ,  and  its  retention  at,  or  even 
above,  the  superior  strait.  This  may  be  accomplished  by  the  ordinary 
means  of  replacement,  and  the  use  of  the  bulb  pessary  (Fig.  192),  in 
difficult  cases,  or  of  one  of  the  varieties  of  intra-vaginal  anteversion  or 
retroversion  pessaries,  in  less  obstinate  ones.  By  a  properly  adjusted 
pessary,  aided  by  complete  removal  of  weight  and  constriction  from  the 
abdomen,  and  the  use  of  an  efficient  abdominal  pad,  the  second  set  of  evils 
may  be  ameliorated.  Relief  of  hemorrhage  generally  proves  difficult,  and 
not  rarely  impossible.  The  presence  of  the  fibroid  in  utero  keeps  up 
congestion  of  the  endometrium,  and  this  results  in  leucorrhcea,  hydrorrhea, 
and  menorrhagia.  Fortunately,  good  can  generally  be,  to  a  limited  extent, 
at  least,  effected  by  rest  in  the  recumbent  posture  during  the  menstrual 
periods;  the  use  of  hemostatic  agents,  as  elixir  of  vitriol,  ergot,  viscum 
album,  cannabis  indica,  gallic  acid,  etc.  ;  and  the  use  of  the  tampon  after 
a  sufficient  loss  has  occurred  to  meet  the  demands  of  ovulation.  The 
practice  of  applying  a  tampon  of  carbolized  cotton  impregnated  with  solu- 
tion of  alum  after  a  menorrhagic  How  has,  under  these  circumstances, 
lasted  for  four  or  five  days,  I  often  resort  to,  and  never  with  any  but 
good  results.  Without  some  such  controlling  influence,  the  patient  will 
commonly  become  greatly  exsanguinated.  While  these  means  are  beins 
adopted  the  bowels  should  be  kept  regular,  and  the  functions  of  the  skin 
and  liver  carefully  supervised. 

In  some  cases  the  engorged  condition  of  the  mucous  membrane  lining 
the  uterus  causes  it  to  become  covered  by  little  fungoid  growths,  which 
keep  up  and  greatly  increase  the  amount  of  hemorrhage.  Under  these  cir- 
cumstances, the  application  of  the  wire  curette  is  of  great  service.  Even 
if  there  should  be  an  error  in  diagnosis,  this  treatment  will  accomplish 
good  by  severing  the  distended  vessels  of  the  mucous  membrane,  and 
relieving  congestion. 

Sliould  it  be  found  that  by  this  means  even,  hemorrhage  is  not  suffi- 
ciently controlled,  resort  should  be  promptly  had  to  palliative  resources 
oi  a  mare   decidedly  surgical  character.      These   may  prove  efficient  as 


CURATIVE    MEDICINAL    MEANS.  529 

hemostatics,  while  at  the  same  time  they  prepare  the  way  for  curative 
means,  if  they  should  he  in  time  deemed  necessary. 

It  has  been  found  that  hemorrhage  due  to  uterine  fibroids  is  often 
greatly  diminished  by  section  of  the  uterine  neck,  a  practice  which  was 
first  inaugurated  by  Amussat,  and  imitated  by  Nelaton,  Brown,  and  Mc- 
Clintock.  In  some  not  very  explicable  manner,  cutting  through  the 
cervical  canal  by  deep  incisions  on  its  sides  exerts  a  good  influence  in 
controlling  this  form  of  hemorrhage.  A  still  more  powerful  effect  will 
follow  incision  directly  through  the  investing  coat  of  the  tumor  itself,  so 
as  to  cut  its  capsule,  its  superficial  layer  of  fibres,  and  its  superficial  blood- 
vessels, and  thus  diminish  its  vascular  supply.  When,  however,  the 
tumor  hecomes  so  accessible  as  to  render  this  possible,  complete  removal 
becomes  so  likewise,  and  should  be  preferred. 

Curative  Medicinal  Means Whether  absorption  of  these  neoplasms 

can  be  excited  by  any  of  those  medicines  styled  absorbents,  is  not  cer- 
tainly ascertained.  Tumors  have  in  some  instances  been  known  to  dis- 
appear while  such  drugs  have  been  employed,  and  perhaps  they  did  so  in 
consequence  of  their  use.  But  no  such  effect  can  be  looked  for  with  any 
confidence.  Indeed,  with  our  present  experience,  such  a  result  must  be 
regarded  as  decidedly  exceptional.  Scanzoni,  after  advising  those  medi- 
cines which  are  most  popular  as  stimulants  of  absorption,  says,  "We  do 
not  remember  a  single  case  in  which,  with  the  means  indicated,  or  with 
others,  we  have  obtained  the  complete  cure  of  a  fibrous  body."  If  such 
drugs  be  tried  for  this  purpose,  they  should  be  continued  for  many  months, 
and  even  a  year  or  two,  before  the  trial  can  be  considered  fairly  made, 
for  their  action  is  never  immediate.  Those  in  greatest  esteem  are  iodine, 
the  iodide  and  bromide  of  potassium  ;  that  class  of  drugs  supposed  to 
possess  the  power  of  inducing  fatty  degeneration,  as  arsenic,  phosphorus, 
and  lead,  "  steatogenic"  drugs,  as  they  have  been  styled;  preparations  of 
lime  ;  and  the  waters  of  certain  mineral  springs,  as  Kreuznach,  Kissingen, 
Krankenheil,  etc.  Some  of  these  waters  may  be  employed  externally  in 
the  form  of  baths  as  well  as  internally. 

About  eight  years  ago,  a  series  of  eight  cases  of  uterine  fibroids  was 
published  by  Hildebrandt,1  of  Konigsberg,  in  which  the  only  treatment 
adopted  consisted  in  the  subcutaneous  injection  of  ergot.  In  seven,  an 
extraordinary  improvement  took  place.  The  theory  of  the  plan  is  this  : 
compression  of  the  tumor  by  ergotic  contraction  of  uterine  fibre  interferes 
with  nutrition  ;  fatty  degeneration  in  consequence  occurs ;  and  the  tumor 
is  thus  rendered  susceptible  of  absorption.  The  results  obtained  by  Hilde- 
brandt were  so  favorable,  that  even  the  most  sanguine  were  led  to  fear  that 
future  experience  might  not  prove  as  successful.     His  method  has,  how- 

1  Berlin  Klin.  Wochenschrift.     Amer.  Journ.  Obstet.,  Nov.  1872. 
34 


530  FIBROID    TUMORS    OF    THE    UTERUS. 

ever,  been  so  far  tested  by  others  that  it  must  be  conceded  that  it  promises 
better  results  than  any  other  which  has  been  employed. 

The  following  is  a  condensed  synopsis  of  some  of  Hildebrandt's  cases : — 

Case  1.  Patient  set.  31 ;  tumor  for  three  years ;  uterus  as  large  as  at 
seventh  month  of  pregnancy ;  hemorrhages  frequent  and  copious.  Injec- 
tions of  ergotine  practised  daily  for  six  weeks,  when  menses  became  regular 
and  painless.  Injections  continued  daily  for  fifteen  weeks  more,  when 
tumor,  which  had  been  growing  smaller  from  week  to  week,  was  found 
to  have  disappeared. 

Case  2.  Under  use  of  injections  uterus  "diminished  in  volume  by  ab- 
sorption of  the  intrauterine  tumor ;  menstruation  became  regular ;  and 
pain  and  leucorrhoea  disappeared." 

Case  3.  Patient  vet.  30;  profuse  sanguineous  discharges,  sometimes 
lasting  from  six  to  eight  months,  since  the  age  of  sixteen.  Anremia  and 
emaciation  extreme ;  fundus  of  uterus  nearly  midway  between  pubis  and 
umbilicus ;  by  touch,  tumor  distinguished  in  the  anterior  wall  of  uterus. 
Subcutaneous  injections  daily  from  January  17th  to  March  5th,  when  the 
patient  was  discharged  ;  menses  regular  ;  general  condition  improved  ;  and 
uterus  notably  diminished  in  size,  the  vaginal  portion  having  in  great  part 
returned  to  its  normal  volume. 

Case  6.  Patient  set.  45  ;  uterus  reached  to  umbilicus  ;  anteverted  ;  large 
fibroid  in  anterior  wall ;  hemorrhage  ;  and  irregular  menses.  After  resort 
to  injections,  improvement  was  well  marked  ;  fundus  descending  to  a  point 
midway  between  umbilicus  and  pubes. 

The  solution  used  by  the  hypodermic  syringe  consisted  of  three  parts 
of  the  aqueous  extract  of  ergot  to  seven  and  a  half  of  glycerine  and  the 
same  of  water.  The  point  of  puncture  was  the  hypogastric  region.  At 
each  injection  three  grains  of  the  extract  were  used. 

In  some  cases  this  treatment  produces  severe  ergotism  at  so  early  a 
period  that  it  has  to  be  desisted  from,  while  at  others  it  results  in  the 
production  of  small  abscesses  of  painful  character.  Hildebrandt  declares 
that  the  introduction  of  the  needle  straight  down  into  the  subcutaneous 
areolar  tissue  obviates  the  occurrence  of  abscesses.  Should  the  subcuta- 
neous method  disagree  with  the  patient,  as  it  did  in  two  out  of  Hilde- 
brandt's nine  cases,  ergot  may  be  given  by  mouth  or  rectum,  with  the 
prospect  of  exciting  tonic  uterine  contraction,  diminishing  vascularity, 
and  lessening  sanguineous  and  mucous  discharges,  and  subsequent  growth 
of  the  tumor. 

Although  the  experience  of  others  with  this  practice  has  not  been  so 
good  as  that  of  Prof.  Hildebrandt,  all  who  have  tested  it  must  admit  that 
his  method  possesses  great  merit,  and  fills  a  place  in  treatment  which  has 
heretofore  been  unoccupied.  Ergot  not  only  acts  by  exciting  uterine 
action  and  thus  interfering  with  the  growth  and  retention  of  the  neoplasm, 
but  it  likewise  causes  contraction  of  the  bloodvessels  themselves,  and  thus 
impairs  nutrition  and  limits  development.     Its  advantages  as  a  palliative 


CURATIVE    MEDICINAL    MEANS.  531 

means  have  been  already  mentioned  ;  in  that  capacity  it  also  acts  in  the 
two  ways,  of  constrictor  of  uterine  fibre  and  of  arterial  muscle.  This 
explains  its  results  in  hemoptysis  and  other  varieties  of  hemorrhage. 
Prof.  Hildebrandt,  in  the  American  Journal  of  Obstetrics,  gives  an 
account  of  19  cases,  and  in  the  Berlin  Klin.  Wochenschrift  of  8  cases,  in 
which  he  has  treated  fibrous  tumors  of  the  uterus  by  hypodermic  injections 
of  ergotine.  Out  of  the  number  3  were  cured;  11  were  diminished  in 
size,  and  the  metrorrhagia  and  leucorrhoca  cured  ;  4  showed  no  effect  from 
the  treatment ;  and  in  9  the  tumor  was  not  affected,  although  the  hemor- 
rhage was  relieved.  One  tumor  of  very  large  size  extending  above  the 
umbilicus  entirely  disappeared. 

He  considers  the  treatment  most  likely  to  result  favorably — 

1st.  When  the  tumor  is  submucous  ; 

2d.  When  the  tumor  is  richly  provided  with  muscular  tissue,  and  pos- 
sesses the  consistence  and  feel  of  a  tense,  elastic  cyst ; 

3d.  When  the  walls  of  the  uterus  are  sound  and  capable  of  vigorous 
contraction  ; 

4th.  When  the  chronic  metritis  or  parametritis  has  been  removed  by 
proper  treatment; 

5th.  When  the  tumor  has  collected  no  capsule. 

Byford  has  collected  101  cases  from  various  sources ;  of  these  he 
reports — 

Cured 22 

Benefited  by  relief  of  hemorrhage  and  leucorrhcoa       .  .  .19 

Tumors  diminished  in  size  and  hemorrhage  removed  .         .     39 

Resisted  treatment      .........     21 

The  best  preparations  for  hypodermic  injection  that  I  know  of  are 
Squibb's  ergotine  dissolved  in  glycerine  and  water,  Merck's  ergotine,  and 
Bartholow's  solution. 

These  should  be  used  fresh,  the  needle  should  be  previously  washed  in 
carbolized  water,  the  fluid  thrown  well  down  into  the  subcutaneous  cellu- 
lar tissue,  and  the  part  gently  rubbed  with  the  palm  of  the  hand  after 
injection  until  all  tumefaction  disappears.  The  injections  should  be  given 
from  three  to  seven  times  a  week. 

Subperitoneal  tumors  are  not  nearly  so  favorably  affected  by  this  method 
as  interstitial  and  submucous  growths.  In  the  last  variety  the  danger  of 
the  creation  of  sloughing  at  a  time  when  the  rigidly  contracted  state  of  the 
os  prevents  resort  to  surgical  procedure  for  immediate  removal  should  not 
be  overlooked.  I  have  seen  quite  a  number  of  fatal  cases  from  this 
cause. 

Hildebrandt's  method  is  a  very  trying  one  for  the  patient.  Many  suffer 
from  abscesses,  some  from  severe  uterine  pains,  while  others  positively 
object  to  the  pain  and  annoyance  of  repeated  punctures  to  such  an  extent 
as  to  cause  the  physician  to  desist  from  treatment. 


532  FIBROID    TUMORS    OF    THE    UTERUS. 

Dr.  Ephraim  Cutter,  of  Boston,  has  obtained  excellent  results  in  these 
cases  from  a  strictly  animal  diet  of  the  most  nutritious  character,  and  the 
passage  of  the  galvanic  current  through  the  tumor  by  puncture  on  each 
side  of  the  abdomen  by  strong  steel  electrodes.  He  declares  that  very 
little  constitutional  disturbance  follows  these  punctures,  and  that  ^reat 
diminution  of  size  commonly  results,  with  occasional  complete  cures. 

In  April,  1880,  Dr.  Cutter  reported  to  the  Boston  Gynecological  Society 
the  following  results  : — 

No.  of  cases  treated  by  electrolysis      ......     50 

No.  in  which  growth  was  arrested       .         .         .         .         .         .32 

No.  in  which  growth  was  not  arrested         .....       7 

No.  which  ended  fatally 4 

No.  which  were  cured         ........       4 

No.  which  were  relieved  merely  ......       3 

Before  taking  up  the  consideration  of  the  surgical  resources  applicable 
to  uterine  fibroids,  I  would  sum  up  the  general  management  of  their 
varieties  in  the  following  manner  : — 

1st.  With  the  means  at  present  at  our  command,  aH  the  varieties  of 
fibroids,  the  subserous,  the  submucous,  and  the  interstitial,  are  amenable 
to  extirpation  ;  but  the  danger  of  removing  the  first  by  laparotomy  is  so 
great  that  this  should  not  be  resorted  to  unless  life  be  threatened  by  the 
non-removal  of  the  tumor. 

2d.  If  an  interstitial  fibroid  be  readily  accessible  by  cutting  through  its 
investing  tissues,  it  should  be  removed. 

3d.  Submucous  fibroids  divide  themselves  into  two  classes,  thus:  if  the 
os  internum  be  obliterated,  and  the  tumor  present  at  or  within  the  os 
externum,  the  case  is  most  favorable  for  removal ;  if  the  os  internum  be 
unyielding,  and  the  cervical  canal  undilated,  danger  will  always  attend 
dilatation  preliminary  to  removal  of  the  growth. 

4th.  In  cases  unfavorable  for  removal  it  is  best  to  resort  to  good  diet, 
tonics,  ergot,  and  means  calculated  to  palliate  symptoms,  and  await  an 
alteration  in  existing  circumstances  which  may  prove  more  favorable  to 
a  resort  to  radical  treatment. 

Curative  Surgical  Procedures The  gynecologist  of  to-day  in  recog- 
nizing the  important  advances  in  his  department,  signalized  by  the  dis- 
covery of  ovariotomy,  the  cure  of  vesico-vaginal  fistula  and  reparative 
operations  upon  the  perineum,  the  uterus,  and  the  vaginal  walls,  often 
forgots  how  much  has  been  done  in  reference  to  the  extirpation  of  uterine 
fibroids  of  all  three  varieties.  Prior  to  the  present  century,  and  even 
during  the  first  half  of  it,  the  operation  of  laparotomy  for  subperitoneal 
tumors  of  this  class  was  unknown ;  interstitial  tumors  were  uninterfered 
with  ;  and  he  who  studies  the  methods  of  those  who  attacked  submucous 
growths  by  the  constricting  ligature,  will  at  once  appreciate  how  hazard- 
ous,  difficult,  and  uncertain  were  the  means  at  the  disposal  of  the  surgeon 
of  the  olden  time  for  dealing  with  them. 


CURATIVE    SURGICAL    PROCEDURES.  533 

The  key-note  to  the  modern  advance  in  this  subject  was  struck  by  the 
late  Dr.  W.  L.  Atlee,  of  Philadelphia,  when  in  the  year  1853  he  presented 
to  the  American  Medical  Association  an  essay  entitled,  "  The  Surgical 
Treatment  of  Certain  Fibrous  Tumors  of  the  Uterus  heretofore  considered 
beyond  the  Resources  of  Art."  This  essay  received  the  prize  of  the  asso- 
ciation, and  to-day  stands  as  the  pioneer  article  in  the  surgical  literature 
of  these  grave  and  otherwise  irremediable  cases. 

Both  in  this  country  and  in  Europe  the  lead  of  this  bold  surgeon  has 
been  followed,  and  the  methods  which  he  advocated  a  quarter  of  a  century 
ago,  and  which  slowly  battled  with  a  pretty  decided  opposition,  have  come 
to  be  recognized  as  legitimate  surgical  resources. 

The  views  of  Atlee,  as  published  in  1853,  may  be  epitomized  in  these 
three  propositions  : — 

First — If  a  non-pediculated  tumor  cannot,  from  the  nature  of  its  attach- 
ment and  envelopes,  be  expelled  or  drawn  by  mechanical  means  through  a 
dilated  os  uteri,  it  is  advisable  to  make  by  the  knife  a  means  of  escape  for 
it  into  the  uterine  cavity,  through  its  capsule  or  enveloping  tissues. 

Second — If  the  tumor  thus  offered  an  outlet  cannot  be  removed,  it 
should  be  forced  into  and  out  of  the  uterine  cavity  by  cutting  the  cervix, 
and  persistently  using  ergot. 

Third — The  tumor,  once  coming  within  reach,  it  should  as  soon  as 
practicable  be  enucleated  or  detached,  and  removed  by  the  surgeon. 

That  this  method  of  treating  such  cases  is  attended  by  the  great  dan- 
gers of  septicaemia,  peritonitis,  hemorrhage,  and  exhaustion,  is  not  to  be 
denied.  But  it  must  be  borne  in  mind  that  while  heroic  interference  is 
environed  by  risks,  a  Fabian  course,  a  policy  of  watching,  waiting,  and 
inactivity,  is  by  no  means  always  a  safe  one.  The  growing  tumor  creates 
exhausting  hemorrhages,  dangerous  mental  depression  and  anxiety,  and 
disturbance  of  the  functions  of  nutrition  and  excretion,  which  slowly  drag 
the  patient  down  to  death. 

The  dangers  attending  strangulation  of  a  uterine  tumor  by  a  constricting 
ligature  are  now  recognized  as  of  so  grave  a  character  as  to  render  every 
cautious  surgeon  averse  to  the  employment  of  this  method,  and  although 
the  boldness  of  the  plans  recommended  by  Atlee  may  appal  the  timid  prac- 
titioner, it  is  now  pretty  generally  appreciated  that  in  apparent  temerity 
there  is  a  degree  of  safety  not  to  be  found  in  measures  which  are  osten- 
sibly milder  and  safer. 

The  plans  now  usually  adopted  for  the  extirpation  of  submucous  and 
interstitial  fibroids  may  thus  be  summarized  : — 
Excision  ; 
Ecrasement ; 
Avulsion  ; 
Enucleation  ; 
The  production  of  sloughing. 


534  FIBROID    TUMORS    OF    THE    UTERUS. 

The  two  elements  which  govern  success  in  the  removal  of  these  growths 
by  the  surgical  processes  which  now  come  to  be  considered  are  these  :  1st, 
the  degree  of  projection  of  the  tumor  into  the  uterine  cavity  ;  2d,  the  de- 
gree of  dilatation  of  the  cervical  canal.  I  do  not  say  that  they  decide  the 
propriety  of  operation.  Removal  may  be  practised  where  the  tumor  is  to 
a  great  extent  interstitial,  only  causing  slight  protrusion  inwards  of  the 
mucous  membrane,  and  where  the  cervical  canal  is  completely  contracted. 
But  in  such  cases  it  is  more  difficult  of  accomplishment,  and  much  more 
dangerous  to  the  life  of  the  patient.  An  interstitial  fibroid  excites  uterine 
contractions,  Avhich  in  time  usually  extrude  it,  making  it  either  subserous 
or  submucous.  In  both  cases  it  carries  with  it  a  covering  of  uterine  tissue, 
which  when  it  enters  the  uterine  cavity  is  one  of  the  influences  which 
prevent  its  expulsion  into  the  vagina  ;  the  closure  of  the  cervix  being 
another.  In  some  cases  nature  unaided  overcomes  these  obstacles.  When 
they  are  too  powerful  for  her,  art  comes  to  her  aid  and  removes  them. 

If  the  cervical  canal  be  sufficiently  dilated  to  allow  of  immediate  access 
to  the  tumor,  much  danger,  delay,  and  trouble  are  avoided  by  that  condition. 
If  it  be  deemed  byst  to  force  open  the  way  to  the  neoplasm,  the  cervical 
canal  may  be  distended  by  cutting  through  it  up  to  the  vaginal  junction, 
and  giving  ergot  to  expand  it ;  by  dilating  it  gradually  by  tents  ;  and  by 
forcibly  dilating  it  by  water  bags,  or  by  graduated  dilators.  Hydrostatic 
dilatation  is  applicable  only  when  the  part  is  dilatable,  and  offers  little 
resistance. 

The  ordinary  water  bags  known  as  Barnes's  dilators  are  not  powerful 
enough  for  the  expansion  of  the  cervix  of  the  non-puerperal  uterus,  and 
besides  this  they  dilate  irregularly.  Molesworth's  dilators,  shown  in  Fig. 
212,  are  by  far  more  efficient  in  these  cases.     This  instrument  consists  of 

Fig.  212. 


Molesworth's  cervical  dilatora. 


a  scries  of  long  bags  of  pure  rubber,  constructed  in  such  a  manner  as  to 
secure  lateral  expansion  without  elongation,  and  a  nickel-plated  force- 
pump,  worked  by  screw  power,  by  which  water  or  air  can  be  forced  into 
the  bag,  to  dilate  it  as  rapidly  or  as  slowly  as  desired.     Each  instrument 


EXCISION, 


535 


has  a  small  stopcock,  enabling  the  operator,  Fie  213. 

if  he  desire,  to  remove  the  pump,  leave  the 
bag  in  position,  ami  thus  continue  dilatation 
for  any  length  of  time. 

Each  instrument  has  several  bags,  the 
smallest  of  which  is  one-eighth  of  an  inch 
in  diameter,  and  capable  of  being  dilated 
to  from  one-half  to  three-fourths  of  an  inch. 
The  largest  bag  is  one-fourth  of  an  inch, 
and  can  be  dilated  to  from  one  to  one  and 
a  half  inches. 

The  method  which  I  have  found  safest 
and  most  certain  for  preparatory  dilatation 
of  the  cervix  is  that  of  cutting  through  its 
walls  laterally  by  Paquelin's'  thermo-cautery 
in  the  direction  shown  by  the  dotted  lines 
in  Fig.  213,  and  then  keeping  the  patient 
under  the  hypodermic  use  of  ergot. 

Excision Should   a    small    submucous 

fibroid  project  into  the  uterine  cavity,  it 
may  be  removed  by  the  severance  of  its  attachment  by  means  of  the  knife, 
scissors,  or  other  cutting  instrument.  If  it  be  within  reach  of  the  knife 
or  scissors,  it  may  be  removed  by  them.  In  case  it  be  attached  higher 
in  the  uterine  cavity,  the  polyptome  of  Aveling  may  be  made  to  answer 
a  good  purpose  (Fig.  214). 


Incision  of  cervix  by  Paquelin's 
knife  for  the  accomplishment  of  dila- 
tation. 


Fig.  214. 


Aveling's  polyptome. 


Removal   may  likewise   be   accomplished  by   the   forceps   of  Nelaton, 
represented  in  Fig.  215,  or  by  long-handled,  curved  scissors,  by  which  as 


Fig.  215. 


N^latou's  forceps. 


much  as  can  be  got  within  their  blades  should  be  cut  away.     In  this  way, 
piece  by  piece,  a  large  portion  or  the  whole  of  the  growth  may  be  excised. 


536 


FIBROID    TUMORS    OF    THE    UTERUS. 


Ecrasement In  many  cases  in  w.hich  excision  may  be  practised,  ecrase- 

ment  becomes  possible  and  should  be  preferred.  The  operation  consists 
in  cutting  off  the  mass,  as  near  its  attachment  as  possible,  by  the  ecraseur. 
This  instrument,  the  invention  of  M.  Chassaignac,  of  Paris,  consists  of  a 

Fig.  216. 


The  6craseur,  straight  and  curved. 


Fig.  217. 


flattened  tube  of  steel  which  has  two  rods  of  the  same  metal  passing 
through  it  to  its  upper  extremity  (Fig.  216).     To  the  end  of  each  of  these 

the  extremity  of  a  chain  is  attached. 
This  is  passed  around  the  part  to  be 
cut  off,  and  the  rods  are  retracted  by  a 
ratchet  movement  at  the  other  extrem- 
ity. Steadily  and  slowly  the  chain 
tightens  around  the  mass  and  cuts  its 
way  through  if.  The  ecraseur  not  only 
presents  the  great  advantage  of  prevent- 
ing hemorrhage,  but  experience  proves 
that  after  its  use  inflammatory  action  is 
much  less  likely  to  occur  than  after 
that  of  cutting  instruments.  Should 
the  tumor  be  small  and  have  passed  out 
of  the  uterus  into  the  vagina,  the  chain 
of  the  ecraseur  may  be  passed  over  it 
as  a  noose,  by  the  fingers.  If  it  be 
small  and  inside  the  uterus,  or  if  the 
tumor  be  of  great  size,  whether  in  the 
vagina  or  uterus,  it  may  be  necessary 
first  to  pass  a  cord  around  it  by  means 
of  canuke,  and  in  this  way  to  draw  in 
place  the  chain,  which  may  be  subsequently  attached  to  the  ecraseur. 

In  many  case  the  use  of  the  ecraseur  is  so  difficult  that  it  becomes  inef- 
fectual. Under  these  circumstances  the  wire  rope  ecraseur  of  Dr.  Brax- 
ton Hicks  answers  a  most  excellent  purpose.     Its  constricting  wire  is  stiff, 


The  ecraseur  at  work. 


AVULSION  —  ENUCLEATION.  537 

small,  and  manageable,  and  thus  we  may  be  able  to  ensnare  a  tumor  which 
was  unattainable  by  Chassaignac's  instrument. 

Should  the  tumor  be  very  large  and  fill  the  vagina  completely,  there 
are  two  methods  by  which  it  may  be  entirely  removed :  1st,  it  may  be 
drawn  down  by  obstetric  forceps  and  delivered;  2d,  it  may  be  cut  away, 
piece  by  piece,  until  its  base  be  reached.  By  the  first  plan  the  uterus  is 
temporarily  inverted,  the  morbid  growth  removed  by  the  knife,  scissors, 
galvano-cautery,  or  ecraseur,  and  the  uterus  replaced,  after  the  stump, 
should  it  bleed,  has  been  seared  by  the  red-hot  iron.  Of  these  I  greatly 
prefer  the  second,  which  I  have  often  practised,  and  never  with  hemor- 
rhage as  a  result. 

Avulsion — The  cervix  being  dilated,  the  tumor  is  seized  by  vulsellum 
forceps  and  firm  traction,  with  slight  rotatory  movement,  made  upon  it. 
Under  this  tractile  force  its  uterine  attachments  may  be  ruptured  and  the 
tumor  come  away.  If  it  do  not  do  so,  the  operator  passes  one  hand  into 
the  vagina  and  two  fingers  into  the  uterus,  by  which  he  ruptures  the 
attachments  of  the  growth  and  thus  frees  it.  Meantime  the  hand  of  an 
assistant  is  placed  over  the  hypogastrium  to  steady  and  depress  the  uterus. 
Dr.  West,1  writing  in  1864,  says,  "The  forcible  avulsion  of  polypi  is  a 
rough  and  hazardous  proceeding,  a  relic  of  barbarous  surgery." 

Enucleation. — Where  the  attachments  of  the  tumor  are  so  extensive,  or 
where  it  is  so  much  embedded  in  the  uterine  parenchyma,  as  to  render  it 
impossible  to  practise  upon  it  any  of  the  procedures  already  described,  the 
operation  of  enucleation  offers  itself  as  a  most  efficient  and  valuable 
resource.  It  has  been  stated  that  the  attachment  of  submucous  and  even 
interstitial  fibroids  to  the  uterine  wall  is  not  firm,  they  being  surrounded 
by  a  layer  of  loose  cellular  tissue.  This  fact  suggested  many  years  ago,  to 
the  mind  of  Velpeau,  the  possibility  of  enucleating  them,  and  in  1840  M. 
Amussat  put  the  theory  into  practice.  At  the  same  time  that  it  must  be 
regarded  as  a  valuable  resource  in  many  difficult  cases,  it  cannot  be  denied 
that  it  is  one  attended  by  great  hazard,  as  it  may  be  destructive  to  life  by 
inducing  exhaustion,  hemorrhage,  perforation  of  the  uterus,  pyaemia,  or 
inflammation  of  the  pelvic  viscera.  Dr.  West  reports  twenty-eight  cases 
in  which  it  was  performed,  fourteen  of  which  proved  fatal. 

"Peritonitis,  phlebitis,  and  pycemia,"  says  Dr.  West,1  in  estimating  the 
prospects  of  success  held  out  by  enucleation,  "  the  consequences  of  vio- 
lence done  to  the  uterus  of  women  exhausted  by  large  and  frequently 
repeated  floodings,  are  dangers  from  which  but  few  have  altogether  escaped; 
under  which  I  fear  that  correct  statistics  will  show  that  most  have  suc- 
cumbed." The  dangers  attending  its  performance  should  not  deter  the 
surgeon  from  resort  to  it  in  suitable  cases  which  absolutely  require  aid. 
They  should  merely  induce  him  to  exhaust  all  palliative  means  before 
resorting  to  this. 

•  Op.  cit.,  Eng.  ed.,  p.  305. 


538  FIBROID    TUMORS    OF    THE    UTERUS. 

Enucleation  may  be  practised  by  two  methods :  immediate,  in  which 
the  fingers  of  the  operator  at  one  sitting  accomplish  the  removal  of  the 
tumor;  and  gradual,  in  which  the  fingers  of  the  operator  merely  inaugu- 
rate the  process  which  contractions  of  the  uterus  are  excited  to  com- 
plete. 

If  the  first  plan  is  to  be  pursued,  the  patient,  after  previous  complete 
dilatation  of  the  cervical  canal,  is  placed  upon  her  back  upon  a  strong 
table,  the  legs  being  held  by  assistants.  An  assistant  firmly  depresses  the 
uterus  by  pressure  on  the  abdomen,  and  the  operator,  by  means  of  a  pair 
of  scissors,  guided  by  two  fingers,  cuts  into  the  capsule.  Into  this  opening 
he  passes  the  index  finger  and  fixes  the  tumor.  By  means  of  scissors  or 
a  probe-pointed  bistoury  a  crucial  incision  is  then  made  through  the  cap- 
sule as  freely  as  circumstances  will  admit.  Passing  one  hand  cautiously 
into  the  vagina,  and  forcing  the  uterus  towards  the  vulva  by  his  other 
hand  and  that  of  an  assistant,  he  now  proceeds  to  peel  back  the  capsule 
and  gradually  to  enucleate  the  mass.  Usually  the  desired  result  will  be 
accomplished,  and  an  artificial  os  thus  offered  for  escape  of  the  tumor  from 
its  capsule.  If  the  vagina  be  not  very  dilatable,  it  had  better  be  prepared 
for  these  manipulations  by  copious  warm  vaginal  injections  and  gradual 
distention  by  water  bags. 

If  the  second  plan1  is  decided  upon,  the  os  being  dilated  or  incised,  a 
long  crucial  incision  is  made  over  the  presenting  part  of  the  tumor,  the 
lips  of  the  capsule  separated  by  the  finger,  and  the  patient  put  upon  the 
steady  and  systematic  use  of  ergot,  in  the  hope  that  the  body  of  the  tumor 
may  present  through  this  species  of  os,  and  be  expelled  by  uterine  efforts. 

Production  of  Sloughing Baker  Brown  and  others  adopted  for  the 

removal  of  these  growths  plans  for  mutilating  them,  and  thus«establishing 
the  process  of  sloughing  by  which,  a  partial  liquefaction  of  their  tissue 
being  effected,  they  could  be  more  readily  discharged  by  uterine  efforts 
or  removed  manually.  I  mention  the  plan  only  to  inveigh  against  it 
in  the  strongest  terms.  It  should  be  cast  aside  for  the  reasons  that  it 
is  attended  by  very  great  dangers,  and  that  much  better  ones  are  at  our 
disposal. 

Although  these  methods  are,  as  I  have  stated,  far  in  advance  of  strangu- 
lation by  ligature,  to  all  of  them  serious  objections  and  deficiencies  attach. 
Excision,  from  the  fact  that  it  is,  except  in  the  case  of  pediculated  growths, 
difficult  to  reach  the  point  of  uterine  attachment  by  knife,  scissors,  or 
polyptome,  is  often  impracticable.  Torsion  can  be  applied  only  to  pedicu- 
lated tumors.  Avulsion  and  enucleation  are  difficult  of  accomplishment, 
slow  of  performance,  and  so  exhausting  to  the  patient  that  she  is  in  dan- 

1  An  excellent  rSsumi of  this  subject,  including  both  the  immediate  and  gradual 
forms  of  enucleation,  will  be  found  in  the  Med.  Times  and  Gaz.,  Aug.  1857,  by 
Mr.  J.  Hutchinson.  I  mention  this  particularly  because  some  more  recent  writers 
appear  to  regard  this  mode  of  dealing  with  fibroids  as  entirely  new. 


EXCISION    WITH    SPOON-SAW. 


539 


ger  of  sinking  in  consequence,  ficrasement  frequently  fails  to  remove  the 
entire  growth,  and  leaves  the  uterine  attachment  to  decompose  and  cause 
septicaemia.  And  the  removal  of  uterine  tumors  hy  the  establishment  of 
the  process  of  sloughing,  insures  so  certainly,  as  has  just  been  stated,  the 
great  dangers  of  septic  poisoning,  that  this  method  should,  in  view  of  the 
fact  that  much  safer  ones  are  at  our  disposal,  be  now  regarded  as  unwar- 
rantable. Instead  of  the  occurrence  of  sloughing  being  courted  by  the 
surgeon,  it  should  in  these  cases  be  feared,  and  avoided  by  all  the  means 
by  which  he  can  oppose  its  development.  One  of  the  great  objections  to 
the  use  of  ergot  as  a  means  of  causing  the  enucleation  or  expulsion  of  large 
submucous  growths  is  the  tendency  of  the  compressing  influence  of  the 
uterine  fibres  to  impair  the  nutrition  of  the  neoplasm  so  completely  as  to 
produce  its  death  and  decomposition. 

Dr.  Emmet  advocates  very  strongly  the  removal  of  fibroids  projecting 
into  the  uterine  cavity  by  firm  traction,  which  he  thinks  causes  the  uterine 
parenchyma  to  expel  the  tumor  in  imitation  of  a  natural  process,  and  then 
cutting  off'  the  most  prominent  part  attainable  in  the  vagina  by  curved 
scissors.  In  this  way  he  reports  the  successful  removal  of  a  number  of 
large  fibroids. 

I  now  proceed  to  lay  before  the  reader  a  plan  which  experience  leads 
me  to  regard  as  superior  to  any  of  these,  and  which  I  believe  will  super- 
sede them  with  all  who  are  willing  to  give  it  a  fair 
trial.     This  method  consists  in  seizing  the  tumor  at  Fig.  218. 

its  most  dependent  and  accessible  point  with  strong 
vulsellum  forceps,  passing  up  along  its  sides  the 
spoon-saw  or  serrated  scoop  depicted  in  Fig.  218, 
and  by  a  gentle,  pendulum  motion  from  side  to  side 
sawing  through  the  attachments  of  the  tumor  and  free- 
ing  it  entirely  from  its  connections  with  the  uterus. 

This  instrument  consists  of  a  steel  spoon  with  a 
strong  handle,  twelve  or  thirteen  inches  long.  The 
spoon  itself  is  slightly  convex  upon  its  outer,  and 
concave  upon  its  inner  surface,  while  its  borders  are 
serrated.  The  saw  teeth  are  blunt  and  not  slanted 
in  either  direction,  but  perpendicular.  The  outer 
convex  surface  protects  the  uterine  wall  entirely, 
while  the  inner  and  concave  causes  the  instrument 
to  hug  the  tumor  and  run  along  its  surface  as  it  cuts 
its  way  laterally  and  upwards. 

The  advantages  which  experience  teaches  me  at- 
tach to  this  instrument  are  the  following:  1st,  the 
attachments  of  the  tumor  are  separated  by  a  saw, 
which  greatly  limits  hemorrhage;  2d,  the  shape  of 
the    spoon,    convex    without    and    concave    within, 

The  spoon-saw. 


540  FIBROID    TUMORS    OF    THE    UTERUS. 

causes  it  to  follow  of  itself  the  contour  of  the  tumor  unless  this  be  very 
lohulated,  and  protect  the  enveloping  uterine  tissues  from  injury ;  3d,  the 
highest  points  of  attachment  of  the  tumor  are  as  readily  reached  as  the 
lowest,  the  freed  growth  descending  under  traction  as  the  saw  severs  its 
adhesions  in  successive  sweeps  around  it;  4th,  the  saw  action  gives  to  the 
process  of  separation,  whether  the  growth  be  interstitial  or  submucous, 
sessile  or  pediculated,  rapidity  and  certainty;  and  5th  and  last,  though  by 
no  means  least,  the  nature  of  the  spoon-saw  secures  separation  of  a  growth 
at  the  highest  point  of  its  attachment,  leaving  no  peduncle  to  decompose. 
Before  endeavoring  to  remove  a  sessile  uterine  fibroid,  it  is  always  ad- 
vantageous to  learn  as  much  as  possible  about  the  degree  of  its  attachment. 
Not  that  even  universal  attachment  should  prevent  the  removal  of  the 
neoplasm  by  means  of  the  spoon-saw,  but  because  here  as  elsewhere 
"knowledge  gives  power,"  and  creates  confidence.  I  have,  after  trying 
various  methods  of  doing  this,  settled  upon  the  use  of  the  flat,  elastic 
whalebone  sound,  which  is  represented  in  Fig.  219. 

Fig.  219. 


Elastic  flat  whalebone  probe. 

The  manner  in  which  I  came  to  employ  this  was  the  following:  Going 
to  the  country  to  remove  a  submucous  fibroid,  I  endeavored  by  means  of 
Simpson's  sound,  Sims's  probe,  and  my  own  round,  elastic  whalebone 
sound  to  discover  the  extent  of  attachment  of  the  growth,  but  for  some 
reason  could  not  succeed.  Taking  then  a  flat  piece  of  whalebone  about 
six  inches  long,  which  one  of  the  ladies  present  removed  on  the  instant 
from  her  dress,  I  put  a  knob  upon  it  by  touching  it  repeatedly  with  melted 
sealing-wax,  and  I  employed  this  with  perfect  success.  This  improvised 
sound  I  took  away  with  me,  and  for  a  year  or  more  employed  it  on  simi- 
lar occasions.  After  that  I  had  one  made  artistically,  which  is  represented 
in  Fig.  219. 

This  sound  is  used  in  this  way:  The  index  finger  of  the  left  hand  is 
placed  on  the  most  accessible  part  of  the  tumor;  then  the  sound,  held  in 
the  right  hand,  is  slid  up  on  one  side  between  the  tumor  and  the  uterine 
wall  until  arrested,  when  the  index  of  the  left  hand  is  placed  upon  its 
shaft  at  the  os  externum  uteri.  The  sound  being  then  withdrawn,  and 
the  finger  kept  upon  it,  it  is  laid  upon  a  sheet  of  paper  or  against  a  black- 
board, and  being  curved,  a  line  is  drawn  from  its  tip  to  the  indicating 


EXCISION    WITH    SPOON-SAW.  541 

finger.  Then  the  sound  is  passed  on  the  other  side,  and  a  similar  trans- 
fer of  its  course  is  made  to  the  sheet  or  board. 

In  this  way  it  is  possible  not  only  to  approximate  the  truth,  but  to  be 
wonderfully  exact  as  to  it.  I  have  repeatedly  demonstrated  the  efficiency 
of  this  sound  to  classes  of  students  and  to  medical  men,  and  I  feel  sure 
that  it  leaves  nothing  to  be  desired  in  reference  to  the  determination  of 
the  degree  of  attachment  of  any  uterine  fibroid  which  can  be  fully  touched 
by  the  finger.     Without  this  possibility  the  method  is  unreliable. 

There  is  no  method  by  which  I  could  so  surely  lay  the  claims  of  this 
instrument  before  the  reader,  and  at  the  same  time  demonstrate  its  appli- 
cation, as  that  of  reciting  two  average  cases  in  which  I  have  employed  it; 
one  a  case  of  submucous  and  one  of  interstitial  fibroid  : — 

Case  I In  June,  1876,  I  was  called  by  Dr.  John  Burke,  of  this  city, 

to  see  with  him  Mrs.  A.,  a  lady  forty-seven  years  of  age,  who  had  been  for 
four  years  suffering  from  a  very  profuse  menorrhagia  and  metrorrhagia. 
To  such  an  extent  had  she  been  reduced  by  loss  of  blood  that  she  Avas 
generally  confined  to  her  chamber,  and  suffered  from  oedema  pedum, 
palpitation  of  the  heart  and  dyspnoea  upon  the  slightest  exertion.  Her 
appearance  was  that  of  one  sulfering  from  an  exaggerated  degree  of 
amemia,  which  was  rapidly  being  aggravated  by  repeated  and  severe 
hemorrhages.  The  liver  was  found  to  be  very  much  enlarged,  as  was 
likewise  the  spleen  ;  the  former,  as  we  supposed,  from  fatty  degeneration, 
the  latter  from  malarial  poisoning. 

Mrs.  A.  had  been  examined  repeatedly  as  to  the  uterine  condition 
during  this  period,  and  twelve  months  before  I  saw  her  Dr.  Burke  had 
discovered  the  existence  of  a  submucous  uterine  fibroid,  supposed  to  be  as 
large  as  the  egg  of  a  goose.  At  no  time  up  to  June,  1876,  did  he  con- 
sider her  in  a  condition  fit  to  admit  of  an  effort  at  the  removal  of  this,  but 
at  that  time  he  called  me  to  decide  whether  it  would  not  then  be  pos- 
sible. 

When  I  first  saw  her  I  found  the  uterus,  "by  conjoined  manipulation,  as 
large  as  it  would  be  in  pregnancy  at  the  fourth  month,  admitting  a  sound 
to  a  distance  of  five  inches,  and  the  tip  of  the  index  finger,  when  force 
was  used,  so  that  a  hard,  pyriform  tumor  could  be  touched  in  the  uterine 
cavity. 

The  patient  was  so  much  exsanguinated,  so  much  exhausted,  and  her 
nervous  system  so  profoundly  depressed,  that  I  decided  against  operation, 
and  she  was  fully  sustained  by  diet  and  fresh  air,  in  the  hope  that  a  few 
months  would  so  improve  her  state  as  to  render  operation  possible. 

I  saw  her  several  times  after  this  with  Dr.  Burke,  but  instead  of  getting 
better,  she  steadily  grew  worse,  and  in  September  general  dropsy  set  in, 
affecting  the  peritoneum  and  the  cellular  tissue  of  the  body.  We  now 
thought  the  case  decided,  and  gave  up  all  hope  of  removal  of  the  uterine 
growth.     In  time,  however,  all  the  effused  fluid  disappeared,  and  about 


542 


FIBROID    TUMORS    OF    THE    UTERUS. 


Fio.  220. 


the  beginning  of  January  she  was  so  far  restored  that  the  question  of 
operation  was  again  agitated.  On  the  loth  interference  was  decided 
upon,  and  on  the  28th  the  tumor  was  detached  and  removed. 

The  following  diagram  represents  the  attachments  of  this  tumor: — 
It  was  free  upon  one  wall  only;  attached  throughout  the  other  to  within 
an  inch  of  the  os  internum. 

At  midday,  on  the  28th  of  January,  detachment  and  extraction  were 
practised  in  the  presence  and  with  the  assistance  of  Drs.  Burke,  Walker, 

and  Jones.  The  patient,  being  etherized,  was 
placed  in  Sims's  position,  and  his  speculum 
was  introduced.  The  cervix  being  then  caught 
with  the  tenaculum,  its  lips  were  severed  on 
each  side,  so  as  to  open  the  way  to  the  tumor, 
which  could  by  the  finger  be  felt  above  before 
this  was  done,  but  now  could  be  quite  freely 
manipulated.  A  powerful  vulsellum  forceps 
was  then  firmly  fixed  in  the  growth,  and  se- 
curely locked.  Then,  with  the  spoon-saw,  the 
uterine  attachments  were  rapidly  and  very 
easily  severed. 

I  was  equally  surprised  and  pleased,  as  were 
also  my  assistants,  at  the  rapidity,  ease,  and 
certainty  with  which  the  sawing  motion  given 
to  this  instrument  by  the  right  hand  separated 
the  tumor  from  the  uterus,  even  at  the  fundus. 
In  a  very  few  minutes  I  had  succeeded  in  de- 
taching and  delivering  a  tumor  which  by  methods  which  I  have  heretofore 
adopted  would  have  taken,  I  think,  at  least  a  half  hour.  Indeed  I  must 
say  that  I  believe  that  in  the  enfeebled  state  of  the  patient  by  no  other 
method  could  it  have  been  removed  without  great  risk  of  fatal  exhaustion. 
The  tumor  weighed  seven  and  a  half  ounces,  and  measured,  in  its  long 
diameter,  four  inches,  and  in  its  short,  three.  It  resembled  in  shape  and 
size  a  large  goose-egg,  and  was  composed  of  the  ordinary  tissue  which 
characterizes  these  myomata. 

The  patient  entirely  recovered,  and  is  now  enjoying  good  health. 

Cask  II Georgiana  P.,  act.  thirty-six  years,  who  has  been  married 

fourteen  years,  and  had  one  child  twelve  years  ago,  since  which  time  con- 
ception has  not  occurred,  was  admitted  to  my  service  in  the  Woman's 
Hospital,  Dec.  20,  1879.  The  patient  was  perfectly  well  until  April,  1879, 
when,  just  after  a  menstrual  period,  she  was  suddenly  seized  with  profuse 
uterine  hemorrhage,  accompanied  by  severe  uterine  tenesmus.  This  lasted 
only  twenty-four  hours,  but  it  exhausted  her  very  much  indeed.  At  every 
menstrual  epoch  which  has  occurred  since  that  time  she  has  had  profuse 
hemorrhage,  with  what  she  styles  "bearing-down  pains."    This  has  lasted 


Attachment  of  fibroid  in  Mrs. 
As  case. 


EXCISION    WITH    SPOON-SAW, 


543 


usually  about  nine  days.  During  the  months  of  July  and  August  she 
suffered  very  much  from  dysuria  and  rectal  tenesmus.  For  the  last  four 
or  five  months  before  admission  she  had  been  almost  entirely  unable  to 
walk,  because  locomotion  created  the  "  bearing-down  pains"  already 
alluded  to.  She  declared  that  up  to  April,  1879,  she  was  in  excellent 
health.  She  was  anaemic,  very  pale,  and  extremely  weak.  During  the 
month  of  October,  hemorrhage  was  so  severe  that  a  vaginal  tampon  had 
to  be  applied  repeatedly  to  check  the  excessive  discharge  of  blood. 

Upon  physical  examination  the  uterus  was  found  very  large,  the  fundus 
extending  up  to  a  point  midway  between  the  umbilicus  and  ensiform  car- 
tilage. The  cervical  canal  was  distended  so  as  to  admit  the  tip  of  the 
index  finger  freely.  The  posterior  uterine  wall,  including  the  cervix,  was 
immensely  hypertrophied,  and  out  of  all  proportion  to  the  anterior.  The 
uterine  cavity,  measured  by  an  elastic  sound,  was  found  to  have  a  depth 
of  nine  and  a  half  inches,  the  sound  passing  upwards  and  then  inclining 
somewhat  backwards  towards  the  spinal  column.  The  following  diagram 
will  convey  a  more  correct  idea  to  the  mind  of  the  reader  than  a  much 
more  lengthy  description  in  words  would  accomplish. 

The  patient,  with  her  husband,  had  come  from  Colorado  Springs,  and 
was  exceedingly  desirous  to  have  some  curative  treatment  adopted,  for 
experience  had  taught  her  the 

inutility  of  the   treatment   by  FlG-  221- 

ergot,  preparations  of  lime, 
and  the  various  other  thera- 
peutical resources  which  are 
ordinarily  adopted  in  cases  such 
as  hers.  Accordingly  she  was 
seen  with  me  in  consultation 
by  a  number  of  my  colleagues 
of  the  hospital  staff,  before 
whose  consideration  I  laid  the 
operation  which  I  shall  now 
describe ;  and  I  was  thoroughly 
sustained  in  the  resort  to  it. 

The  propriety  of  the  opera- 
tion and  the  urgent  demand 
for  prompt  action  in  this  case 
were  from  the  first  quite  clear 
to  my  mind,  and  at  no  time  did 

any  doubts  as  to  the  justice  of  this  conclusion  present  themselves 
reasons  for  my  convictions  were  the  following: — 

1st.  My  experience  with  the  spoon-saw  in  a  large  number  of  cases  made 
me  feel  confident  that  success  would  crown  my  efforts  as  to  the  mere  sur- 
gical part  of  the  work. 


Diagram  representing  the  tamor  imbedded  in  the 
posterior  wall  of  the  uterus.  1  shows  the  projecting 
posterior  wall;  2,  the  uterine  cavity;  3.  the  tumor; 
4,  anterior  uterine  wall  at  the  point  of  attachment  of 
the  anterior  vaginal  wall. 


The 


544  FIBROID    TUMORS    OF    THE    UTERUS. 

2d.  The  tumor,  already  large,  was  growing  fast,  and,  in  a  few  months, 
the  abdomen  would  have  had  to  be  opened  to  give  exit  to  it. 

3d.  The  patient  was  losing  large  amounts  of  blood,  and  growing,  of 
course,  steadily  weaker,  and  progressively  more  despondent. 

4th.  She  lived  in  Colorado,  far  away  from  any  surgical  centre,  and,  if 
she  were  sent  away  now,  it  was  highly  improbable  that,  weakened  by 
hemorrhage,  discouraged  by  failure  to  obtain  relief  from  surgery,  and 
alarmed  by  the  great  and  increasing  size  of  the  abdomen,  she  would  ever 
again  make  an  attempt  to  save  her  life.  In  the  present  I  saw  a  courage- 
ous and  comparatively  strong  and  healthy  woman,  with  a  fairly  good  blood 
state,  unimpaired  nerve  condition,  efficient  digestive  function,  and  a  tumor 
weighing  two  pounds,  not  willing  merely,  but  eager  for  operation.  In  the 
future  I  foresaw  an  anaemic,  feeble,  and  despondent  one  with  impaired 
digestion,  an  exhausted  nervous  system,  and  a  tumor  weighing  eight  or 
ten  pounds,  still  willing  to  submit  to  operation  perhaps,  but  doing  so  with 
diminished  hope  and  lessened  enthusiasm. 

On  the  5th  of  January  I  proceeded  to  remove  the  tumor  in  the  following 
manner,  and  in  the  presence  of  Prof.  Alfred  C.  Post,  and  Drs.  Emmet, 
C.  C.  Lee,  J.  B.  Hunter,  C.  S.  Ward,  II.  D.  Nicoll,  S.  B.  Jones,  and 
the  house  staff  of  the  hospital.  The  patient,  having  been  etherized,  was 
placed  in  Sims's  position  upon  a  strong  table  before  a  window  admitting 
a  good  light.  During  the  steps  of  the  operation  I  was  ably  assisted  by 
the  assistant  surgeons  in  my  department,  Drs.  Ward  and  Nicoll.  Sims's 
largest  speculum  having  been  introduced,  and  the  perineum  and  posterior 
wall  of  the  vagina  lifted  by  it,  I  caught  the  uterine  wall  at  the  point 
marked  by  the  figure  1  (Fig.  221),  and,  by  means  of  a  pair  of  long-handled 
scissors,  snipped  a  piece  out  of  it,  extending  deeply  into  its  structure. 
Upon  this  a  very  free  flow  of  blood  occurred,  but  I  disregarded  it,  and  as 
I  proceeded  with  the  operation  it  very  soon  ceased.  Keeping  a  strong 
tenaculum  fixed  in  the  uterine  tissue  between  the  figure  1  and  the  poste- 
rior vaginal  walls,  I  now  passed  my  right  index  finger  into  the  opening 
which  I  had  made,  and  in  this  way  enlarged  it  somewhat.  Then  taking 
a  very  strong  and  large  grooved  director,  I  forced  it  upwards  towards  the 
figure  2,  and  sliding  a  knife  in  its  groove,  I  slit  the  enveloping  uterine 
wall  high  up  into  the  uterine  cavity.  By  the  finger  I  now  enlarged  the 
opening  thus  made,  and  was  at  once  gratified  by  the  sight  of  the  white 
fibrous  structure  of  the  tumor  of  which  I  was  in  search.  Into  this  I  at 
once  fixed  a  powerful  pair  of  vulsellum  forceps,  and  taking  the  spoon-saw 
swept  it  around,  and  detached  the  tumor  from  its  uterine  bed  for  about  an 
inch  and  a  half  or  two  inches  all  around. 

I  now  made  traction  upon  it  with  the  vulsellum,  but  found  that  the 
tumor  was  too  large  to  be  dragged  down  into  the  pelvis.  Taking,  then,  a 
pair  of  long-handled  scissors,  I  cut  out  the  portion  of  the  tumor  within 
the  bite  of  the  forceps,  removing  a  piece  about  as  large  as  a  hen's  egg. 


LAPAROTOMY.  545 

Then  seizing  another  portion  of  the  tumor,  I  cut  it  out,  and  continuing  in 
this  way  I  removed,  piecemeal,  all  that  portion  which  I  had  detached  by 
the  spoon -saw. 

I  now  seized  the  tumor  again  with  the  vulsellum  forceps,  and  detach- 
ing, by  means  of'  the  spoon-saw,  about  an  inch  and  a  half  more  of  it,  I 
removed  it  piecemeal  by  the  scissors  as  already  described.  This  process 
I  repeated  till  about  one-third  of  the  tumor  only  remained,  when  1  de- 
tached the  entire  mass  with  the  spoon-saw,  and  drew  it  away. 

The  operation  lasted  one  hour  and  twenty  minutes.  After  the  first  inci- 
sion it  was  accompanied  by  almost  no  hemorrhage,  and  the  patient  bore 
it  remarkably  well.  At  its  conclusion  the  large  cavity  left  by  the  re- 
moval of  the  tumor  was  syringed  out  with  strongly  carbolized  water,  and 
stuffed  to  its  full  capacity  with  carbolized  cotton.  The  patient  was  put  to 
bed;  given  a  full  dose  of  morphia  hypodermically  ;  kept  very  warm  by 
the  application  of  artificial  heat;  as  soon  as  she  could  swallow,  given 
brandy  and  water  in  small  amounts  at  short  intervals,  and  kept  upon  the 
general  regimen  usually  adopted  as  preventive  of  shock. 

I  shall  not  weary  the  reader  with  a  detailed  account  of  the  progress  of 
the  case  ;  suffice  it  to  say,  that  no  bad  symptoms  developed  themselves, 
and  that  just  one  month  after  the  performance  of  the  operation,  the  patient 
left  the  hospital  for  her  home. 

The  tumor  weighed  exactly  two  pounds,  and  was  a  good  example  of  the 
ordinary  myo-fibroma.  It  must  be  remembered  that  its  duration  is  un- 
known. True,  it  was  discovered  in  April,  1879,  but  it  is  highly  probable 
that  it  had  existed  long  before  that  time. 

At  the  conclusion  of  the  operation,  an  eminent  surgeon  who  was  present 
remarked  that  he  was  surprised  that  I  had  depended  so  little  upon  the 
spoon-saw  in  its  performance.  !My  own  feeling  in  regard  to  the  matter  is 
this :  without  the  spoon-saw  nothing  would  have  induced  me  to  touch 
this  case;  with  it  at  my  disposal,  I  would  willingly  undertake  to  cope  with 
any  number  of  similar  ones.  After  having  detached  segment  after  seg- 
ment of  the  lower  portion  of  the  tumor,  dismemberment  and  removal  of 
parts  of  it  were  easy.  An  attempt  to  excise  and  remove  the  growth  before 
detachment  would,  I  think,  have  very  soon  been  followed  by  the  filling  of 
the  vaginal  canal  with  intestines. 

I  have  now  operated  more  than  twenty  times  with  the  spoon-saw,  and  its 
efficiency  becomes  more  and  more  apparent  with  increasing  experience.  At 
present  I  resort  to  no  other  means  for  removal  of  intra-uterine  growths  which 
are  firm  and  large  enough  to  admit  of  traction  by  the  vulsellum  forceps. 

Laparotomy One  of  the  great  questions  of  the  future  in  gynecology  is 

to  be  not  the  propriety  but  the  proper  limitation  of  the  operation  of  lapa- 
rotomy for  the  removal  of  uterine  fibroids,  involving,  as  it  very  commonly 
does,  the  ablation  of  a  part  or  the  whole  of  the  uterus.  Indeed,  no  ope- 
rator should  undertake  gastrotomy  for  a  uterine  fibroid  without  being  pre- 
3o 


546  FIBROID    TUMORS    OF    THE    UTERUS. 

pared,  if  necessary,  to  remove  the  uterus  with  the  tumor,  for  the  connec- 
tion is  often  so  intimate  that  a  determination  of  the  attachments  of  the 
tumor  is  out  of  the  power  of  the  most  skilful  diagnostician.  Indeed,  even 
after  removal  of  the  mass  from  the  body,  its  relations  to  the  uterus  are 
often  discovered  only  after  patient  and  intelligent  search.  Dr.  Farre  tells 
of  a  specimen  preserved  in  one  of  the  London  museums  as  a  solid  ovarian 
tumor  which,  upon  careful  examination,  he  proved  to  be  uterine  by  tracing 
the  Fallopian  tubes  into  it.  It  was  also  in  this  way  that  the  nature  of  a 
tumor  removed  by  Dr.  Storer  was  identified  ;  Prof.  Ellis,  after  a  very 
minute  examination,  distinctly  discovering  the  entrance  of  the  tubes  into 
the  cavity  of  the  body,  and  thus  settling  the  matter. 

I  have  said  that  the  future  would  concern  "  not  the  propriety"  of  the 
operation  of  uterine  extirpation  for  fibroids,  for,  although  all  conservative 
men  must  condemn  the  reckless  resort  to  the  operation,  which  is  sometimes 
practised  at  present,  all  progressive  men  should,  I  think,  be  agreed  that 
under  certain  circumstances  it  is  not  only  an  admissible  but  a  necessary 
procedure.  The  point  of  difference  should  be,  to-day,  not  the  legitimacy 
but  the  indications  for  the  operation. 

"Seeing  the  results  of  the  operation  in  this  country,"  says  Emmet,  "no 
surgeon  is  justified  in  attempting  to  remove  the  uterus  for  the  growth  of 
a  fibrous  tumor  except  as  a  forlorn  hope."  "  At  present,"  says  Barnes, 
"there  is  little  ground  for  enthusiastic  advocacy  of  the  practice.  The  case 
may  best  be  summed  up  by  stating  that  the  question  is  ad  hoc  sub  judice." 
These  two  eminent  gynecologists  may  be  said  to  reflect  the  general  con- 
servative sentiment  of  the  profession.  And  yet  this  adverse  inclination  in 
the  professional  mind  is  no  more  marked  than  it  was  a  quarter  of  a  cen- 
tury ago  with  reference  to  ovariotomy,  the  crowning  glory  of  gynecological 
surgery.  It  must  be  remembered,  on  the  one  hand,  that  many  cases  in 
which  removal  of  a  large  fibroid,  which  has  involved  the  ablation  of  the 
whole  uterus,  have  recovered,  and  it  must  be  appreciated,  on  the  other,  that 
the  surgeon  who  refuses  the  chances  of  operation  to  one  who  is  failing  from 
the  existence  of  a  uterine  fibroid,  should  pause  when  he  reflects  that  a  tumor, 
the  removal  of  which  appears  to  be  exceedingly  difficult,  may  prove  upon 
experiment  to  be  extremely  easy.  Two  cases  of  my  own  will  illustrate 
this  remark.  Fifteen  years  ago  Prof.  F.  N.  Otis  brought  to  me  for  con- 
sultation  a  patient  who  had  a  very  large  uterine  fibroid,  and  I  decided 
against  the  advisability  of  operation.  In  time  the  patient  died,  and  a 
colossal  tumor  was  found  unattached  in  the  abdomen,  connected  with  the 
uterus  by  a  small  pedicle,  which  could  easily  have  been  severed.  Five 
months  ago  a  Swedish  woman  presented  herself  in  my  service  in  the 
"Woman's  Hospital  with  an  abdominal  tumor,  weighing  about  fifty  pounds, 
which  had  undoubtedly  existed  for  twenty-three  years.  Of  this  fact  we 
had  positive  proof,  apart  from  her  own  statement.  I  felt  inclined  to  regard 
the  tumor  as  a  uterine  fibro-cyst,  and  operated  with  the  belief  that  I  should 


Pean* 

collect 

ed     44 

Pozzi2 

" 

119 

Boinet 

(i 

46 

A.  Leblond3 

" 

12 

Storer4 

it 

24 

Thomas5 

a 

12 

Schroeder6 

u 

108 

42 

12          "            < 

8 

6 

1 

30          "            ' 

STATISTICS    OF    LAPAROTOMY.  547 

have  to  remove  the  whole  uterus.  The  tumor  proved  to  be  ovarian,  and 
the  patient  rapidly  recovered. 

The  warmest  advocate  of  uterine  ablation  for  fibroids  has  been  M.  Pean, 
the  celebrated  surgeon  of  Paris.  In  1873  he  published  statistics,  which 
will  soon  be  cited,  and  made  the  following  declarations  :  "Amputation 
of  the  supra-vaginal  portion  of  the  uterus  is  not  an  operation  of  much 
graver  character  than  extirpation  of  ovarian  cysts  complicated  by  adhe- 
sions." ....  "Ablation  of  the  uterus  is  a  perfectly  justifiable  ope- 
ration, which  the  surgeon  is  as  much  warranted  in  undertaking  under 
certain  circumstances  as  ovariotomy."  At  that  time  he  reported  nine 
operations,  with  seven  recoveries,  and  yet  during  the  past  seven  years  no 
further  report  has  emanated  from  him. 

Statistics — No  reliable  statistical  report  on  the  subject  exists,  so  far  as 
my  knowledge  goes,  so  that  I  shall  have  to  content  myself  with  fragmen- 
tary evidence. 

44  cases,  of  which  14  recovered  and  30  died. 

77  " 
34     " 

4  " 

18  " 

11  " 

78  " 

Of  Schroeder's  cases,  73  with  removal  of  the  uterus  gave  55  deaths  and 
18  recoveries  (24TG<JG5-  per  cent.)  ;  while  35  operations,  without  removal  of 
the  uterus,  gave  23  deaths  and  12  recoveries  (34T3^  per  cent.) 

It  would  not  be  safe  to  generalize  from  all  these  cases,  for  without 
doubt  many  of  the  same  cases  have  entered  into  the  calculations  of  several 
authorities.  Having  at  hand  no  better  material,  I  present  this  in  its  crude 
state. 

Let  us  remember  that  antiseptic  surgery  has  just  dawned  upon  science, 
and  let  us  hope  that  the  statistics  of  the  future  will  show  a  great  advance 
over  those  of  the  past. 

Supported  by  such  statistical  evidence,  it  is  certainly  not  venturing  too 
much  to  say,  that,  if  a  fibroid  be  pedunculated  and  unattached,  its  re- 
moval is  not  much  more  dangerous  than  the  ordinary  operation  of  ovari- 
otomy was  a  few  years  ago ;  that,  if  it  be  completely  amalgamated  with 
the  uterus,  or  so  bound  to  neighboring  parts  that  removal  proves  very 
difficult,  the  operation  may  be  abandoned,  the  patient  having,  without 
great  risk,  availed  herself  of  the  only  chance  of  cure  ;  and  that,  even  if 
the  removal  of  the  tumor  involve  that  of  the  uterus  and  ovaries,  we  may 

1  Hysterotomie,  par  J.  Pean  et  L.  Urdy,  Paris,  1873. 

2  Pozzi,  These  d'agregation,  1875. 

3  Traite  Elem.  de  Chirurg.  Gynecol.,  Paris,  1878. 

4  Successful  Removal  of  Womb  and  both  Ovaries,  1866. 

6  Dis.  of  Women,  1874.  6  Dis.  of  Female  Sexual  Organs. 


548  FIBROID    TUMORS    OF    THE    UTERUS. 

still  indulge  in  a  fair  hope  of  saving  our  patient.  Surely,  when  ablation 
of  the  entire  uterus,  as  an  addendum  to  the  Coesarean  section  and  as  a 
remedy  for  cancer,  is  winning  the  position  of  a  warrantable  procedure  by 
reason  of  the  success  attending  it,  he  who  allows  death  to  occur  from 
uterine  fibroids  without  offering  his  patient  the  chance  of  safety  possible 
from  gastrotomy,  is  assuming  a  responsibility  far  greater  than  that  which 
would  attend  an  honest  and  well  directed  effort  to  save  life. 

The  same  arguments  which  can  be  urged  in  favor  of  ovariotomy  do  not, 
however,  apply  to  this  procedure.  Ovarian  tumors  almost  always  run  a 
rapid  course  toward  death  ;  fibroid  tumors  do  so  only  exceptionally.  The 
former  are  not  ameliorated  by  the  menopause ;  the  latter  are  usually 
greatly  benefited  by  it. 

The  accidents  which  have  generally  produced  a  fatal  termination  in 
cases  of  gastrotomy  are  as  follows  : — 

1st.  Primary  or  secondary  shock  or  collapse  ; 
2d.  Hemorrhage ; 
3d.  Peritonitis ; 
4th.  Septicaemia. 
We  are  now  possessed  of  means  for  limiting  the  first ;    the  improved 
methods  of  hemostasis  at  our  command  diminish  the  danger  of  the  second  ; 
and  the  knowledge  of  the  fact  that  antiseptic  surgery  markedly  diminishes 
the  probability  of  the  occurrence  of  the  third  and  fourth,  will  in  future  aid 
in  avoiding  them. 

Methods  of  Removal. — I  shall  now  proceed  to  describe  three  operative 
procedures,  the  first  that  of  Pean ;  the  second  that  of  Schroeder ;  and 
the  third  my  own. 

Pearis  Operation — This  is  divided  into  three  stages.  The  first  one 
consists  in  making  an  abdominal  incision  through  the  median  line,  ex- 
tending downwards  to  one  inch  above  the  symphysis  pubis,  and  upwards 
towards  the  umbilicus  as  short  a  distance  as  is  compatible  with  exposure 
of  the  surface  of  the  tumor. 

Second  Stage — If  any  fluid  exist  in  the  tumor  it  should  be  evacuated 
by  puncture  by  a  trocar  or  canula.  If  it  be  small  enough,  either  before 
or  after  this,  to  be  drawn  through  an  abdominal  opening  of  moderate  size, 
this  should  be  done,  and  the  operator  may  at  once  proceed  to  the  third 
stage.  If  it  be  solid  and  too  large  to  be  drawn  out,  it  should  be  removed 
piecemeal  in  the  following  manner.  By  means  of  a  long,  curved  needle, 
two  or  three  strong  wires  are  carried  deeply  into  the  tumor  and  tightly 
twisted,  so  as  to  constrict  the  vessels,  and  the  intervening  mass  is  cut 
away.  Then  another  portion  is  similarly  treated  until  the  tumor  is  small 
enough  to  be  drawn  out.  Adhesions  are  then  carefully  tied  and  broken, 
and  the  tumor  is  delivered. 

Third  Stage The  tumor  being  held  up  by  one  assistant,  while  another 

closes  the  abdominal  wound  to  prevent  escape  of  the  intestines;  the  uterus 


METHODS    OF    REMOVAL.  549 

is  penetrated  by  the  long,  curved  needle  near  the  os  internum,  or  even 
lower  if  the  tumor  extend  downwards ;  wires  .are  drawn  into  place  ;  the 
two  halves  of  the  cervix  are  compressed  by  twisting  them ;  the  tumor  is 
cut  off;  and  the  pedicle  thus  formed  is  fixed  in  the  wound. 

The  wound  is  then  closed,  and  the  pedicle,  which  is  kept  in  the  abdomi- 
nal wound  by  means  of  the  instruments  by  which  the  wires  were  twisted, 
is  treated  as  after  ovariotomy. 

Sckroeder's  Operation.1 — The  abdominal  incision  having  been  made  in 
the  median  line,  and  the  uterus  and  tumor  exposed  to  view,  a  needle  is 
passed  at  the  os  internum  and  strong  ligatures  applied.  This  cuts  off  the 
blood  supply  to  the  tumor,  which  is  cut  to  pieces  as  we  would  cut  a  melon 
and  removed.  The  incision  by  which  the  uterus  is  removed  is  wedge- 
shaped,  and  the  edges  of  the  wound  are  approximated  by  deep  and  arti- 
ficial sutures,  so  that  the  opposing  edges  of  the  peritoneum  come  into 
contact,  and  the  stump  thus  arranged  is  dropped  into  the  peritoneum. 
Schroeder  has  operated  for  tumors  of  the  uterus  six  times,  with  five  recov- 
eries. German  operators  seem  to  be  pretty  uniformly  agreed  that  return  of 
the  pedicle  to  the  abdominal  cavity  and  complete  closure  of  this  is  an  essen- 
tial to  a  successful  system  in  this  operation.  The  validity  of  this  position 
is,  however,  by  no  means  proved.  Very  surely,  the  external  treatment 
of  the  pedicle  does  not  invalidate  the  perfect  practice  of  Lister's  antiseptic 
methods  where  proper  precautions  are  used  in  renewal  of  the  dressings. 

Thomas's  Operation — The  abdominal  walls  are  incised  as  for  ovari- 
otomy, and  all  cystic  formations  emptied  by  the  trocar  and  canula.  The 
lowest  portion  of  the  tumor  is  then  manipulated  so  that  a  strong  cord,  a 
piece  of  cod  line,  for  example,  is  passed  under  it.  By  this  the  pelvic 
extremity  of  the  tumor  is  lifted  so  that  one  limb  of  the  clamp,  shown  in 
Figs.  222  and  223,  which  measures  nine  and  a  half  inches  in  length,  can 
be  passed  under  it.  The  second  limb  of  the  clamp  is  then  screwed  to  the 
first,  the  tumor  cut  through,  the  severed  end  of  it  drawn  down  by  vulsella, 
and,  the  entrance  of  blood  to  the  peritoneal  cavity  being  prevented  by  stuf- 
fing napkins  under  and  around  the  bleeding  surface,  the  mass  is  diminished 
in  size  by  the  knife,  and  removed  as  rapidly  as  possible.  The  pedicle  is 
then  examined,  and,  if  it  be  found  practicable,  a  second  clamp  is  placed 
lower  down,  the  first  removed,  and  additional  tissue  cut  away  above  the 
lower  one.  The  clamp  is  kept  in  place  during  the  progress  of  the  case  as 
after  ovariotomy. 

Should  this  manoeuvre  be  found  to  be  impossible  from  the  great  bulk  of 
the  lower  segment  of  the  tumor,  the  incision  is  prolonged  to  such  an  extent 
that  the  tumor  can  be  delivered  with  a  certain  degree  of  force.  Two 
assistants  then  lift  it  as  high  in  the  air  as  possible,  and  the  attachment 
of  the  bladder  to  the  tumor  being  examined  by  a  catheter,  the  former  is 
detached  from  the  latter  if  this  be  found  necessary.     As  near  to  the  vaginal 

1  Amer.  Journ.  Obstet.,  Jan. '1879. 


550 


FIBROID    TUMORS    OF    THE    UTERUS. 


junction  as  it  can  be  placed,  the  large  clamp  is  then  applied  and  screwed 
so  firmly  as  to  control  hemorrhage. 


Fig.  222. 


Thomas's  clamp,  open. 
Fig.  223. 


Thomas's  clamp,  closed. 


By  this  means  the  portion  of  the  tumor  which  is  to  be  used  as  a  pedicle 
is  compressed,  and  as  far  as  possible  diminished  in  bulk.  The  tumor  and  as 
much  of  the  uterus  as  is  above  the  clamp  is  now  cut  off.  The  clamp  is  thus 
far  used  as  the  main  hemostatic  agent ;  but  it  is  not  to  be  thus  employed 
permanently.  Three  or  four  steel  knitting  needles  are  now  passed  through 
the  tissue  just  above  the  clamp,  at  right  angles,  so  as  to  support  the  part 
after  the  clamp  is  loosened.  Then  by  large  cautery  irons  the  tissue  above 
clamp  and  needles  is  thoroughly  charred.  This  is  the  permanent  hemosta- 
tic power  upon  which  dependence  is  placed,  and  to  render  it  reliable  the 
whole  inch  of  pedicle  above. the  clamp  should  be  completely  charred.     The 


FIBRO-CYSTIC    TUMORS    OF    THE    UTERUS.  551 

clamp  is  now  loosened,  the  ordinary  antiseptic  dressing  applied,  and  the 
patient  put  to  bed  and  closely  watched  for  evidences  of  hemorrhage  or 
shock.  The  first  should  be  met  by  tightening  the  screws  of  the  clamp ; 
the  second  by  hypodermic  injections  of  morphia,  brandy,  and  ether,  and 
by  warmth  to  the  entire  body,  and  especially  to  the  soles  of  the  feet  and 
palms  of  the  hands. 

I  have  now  removed  the  uterus,  in  whole  or  in  great  part,  on  account 
of  tumors  seven  times,  with  lour  recoveries  and  three  deaths.  In  no  case 
was  the  operation  one  of  election ;  in  every  case  it  was  a  matter  of  neces- 
sity, the  patients  in  every  instance  having  the  choice  between  uterine 
extirpation  and  death. 

These  operations,  like  all  others  in  abdominal  surgery,  should,  with  the 
light  which  we  at  present  have  upon  the  subject,  be  performed  under  the 
antiseptic  method. 

On  the  twelfth  or  fourteenth  day  the  clamp  may  be  cautiously  removed. 
During  the  last  two  months  I  have  twice  removed  the  entire  uterus  by  this 
method,  with  the  recovery  of  both  patients. 

Oophorectomy Extirpation  of  the  ovaries,  castration,  Battey's  opera- 
tion, has  been  now  repeatedly  performed  for  the  premature  induction  of 
the  menopause,  for  the  control  of  the  exhausting  hemorrhage  which  so 
commonly  marks  these  cases. 

The  operation  has  been  performed  for  the  fulfilment  of  this  indication, 
where  uterine  tumors  have  existed,  as  follows  : — 

Hegar1  has  operated  12  times,  with  9  recoveries  and  3  deaths. 
Freund  "  3  "  2         "  "     1      " 

Goodell  "  1  "  0         "  "     1      " 

Mann  "  1  "  0         "  "     1       " 

Total  number  of  cases,    17  "        11         "  "     6      " 

Hegar,  whose  experience  with  the  operation  is  greater  than  that  of  any 
other  authority,  regards  its  efficacy  in  very  large  fibroids  as  doubtful. 


CHAPTER    XXXV. 

CYSTO-FIBROMATA,  OR  FIBRO-CYSTIC  TUMORS  OF  THE  UTERUS. 

Definition,  Synonyms,  and  Frequency. — The  form  of  compound  uterine 
tumor  which  we  are  now  considering  has  been  described  by  different 
authors  under  the  names  of  cysto-fibroma,  cysto-sarcoma,  cysto-myoma, 
cystoid  and  fibro-cystic  tumor. 

1  See,  with  reference  to  this  subject,  a  paper  by  Dr.  Mann,  Arehiv  of  Med.,  vol. 
iv.  No.  1,  Feb.  1860. 


552  FrBRO-CYSTIC    TUMORS    OF    THE    UTERUS. 

Our  knowledge  of  these  tumors  is  but  recently  acquired,  and  is  even  now 
exceedingly  elementary.  In  two  of  its  most  important  aspects,  diagnosis 
and  differentiation  from  other  forms  of  abdominal  tumor,  we  have  been 
very  deficient,  and  from  this  have  resulted  frequent  and  serious  errors. 
Considerable  attention  is,  however,  being  now  directed  to  the  subject,  and 
already  we  are  possessed  of  means  which  were  wanting  only  a  few  years 
ago  for  arriving  at  correct  and  certain  conclusions  concerning  them. 

Cysts  may  develop  in  connection  with  the  uterus  in  two  entirely  differ- 
ent ways:  first,  a  cyst  may  grow  and  become  very  large,  being  enveloped 
by  a  layer  of  uterine  tissue  ;  second,  solid  tumors  of  the  uterus,  whether 
benign  or  malignant,  may  undergo  cystic  degeneration,  that  is  to  say, 
within  the  structure  of  a  solid  tumor  cysts  may  develop,  which,  distending 
the  spaces  in  which  they  first  form,  gradually  increase  in  size,  and  it  may 
be  in  number,  until  what  was  formerly  a  solid  growth  becomes  in  certain 
parts  filled  with  fluid.  Thus  we  may  have  cysto-sarcoma,  cysto-fibroma, 
cysto-chondroma,  or  cysto-carcinoma. 

It  must  not  be  supposed  that  this  variety  of  tumor  compares  in  fre- 
quency with  the  simple  fibroid,  or  that  cystic  degeneration  often  affects 
that.  It  is  not  a  matter  of  very  common  occurrence,  but  it  is  certainly 
sufficiently  common  to  demand  especial  consideration  at  the  hands  of  the 
gynecologist.  As  has  been  the  case  too  with  many  other  affections,  as 
soon  as  special  attention  has  been  directed  to  it,  it  has  been  found  to  be 
much  more  frequent  in  occurrence  than  was  previously  supposed.  Up  to 
the  year  1869,  Kceberle1  tells  us  that  only  fourteen  cases  had  been  recorded, 
of  which  two  were  discovered  post  mortem.  Dr.  C.  C.  Lee,2  however,  in 
that  year,  collected  the  reports  of  nineteen  cases,  nine  in  this  country, 
eight  in  England,  and  two  in  France.  Dr.  E.  R.  Peaslee,3  writing  in 
1872,  says,  "  I  have  myself  met  with  ten  cases  in  the  last  two  years,  atid 
have  seen  not  less  than  fifty  since  my  first  operation  of  ovariotomy  in  1850." 

Pathology. — Pathologists  describe  a  variety  of  methods  by  which  spaces 
may  be  created  within  fibroid  tumors,  which,  subsequently  becoming  lined 
by  a  fluid-secreting  membrane,  are  filled  with  serous,  sero-sanguinolent,  or 
colloid  material.  "Within  some  fibroid  tumors,"  says  Klob,' "cavities 
may  be  found,  which  may  have  occurred  in  several  ways.  They  either 
result  from  a  dropsical  condition,  or  the  connective  tissue  of  the  tumor 
undergoes  colloid  metamorphosis  (mucous  degeneration),  commencing  at 
the  centre  of  the  tumor,  and  in  consequence  of  which  its  substance  lique- 
fies into  an  albumino-serous  fluid.  Finally, hemorrhages  into  thesubstance 
of  a  tumor  may  lead  to  the  formation  of  cavities  similar  to  the  so-called 
'apoplectic  cysts.' "     In  speaking  of  neoplastic  cysts,  Billroth5  says,  "  These 

1  Gazette  Hebdom.,  No.  16,  1869. 

*  Remarks  upon  Diagnosis  of  Ovarian  from  Fibro-Cystic  Tumors. 

3  Ovarian  Tumors,  p.  107/  *  Op.  cit.  5  Op.  cit.,  p.  621. 


PATHOLOGY.  553 

result  mostly  from  softening  of  tissue  previously  diseased  by  cell-infiltra- 
tion,  or  a  firm  tumor  substance.  As  soon  as  the  new  formation  has  sepa- 
rated into  sac  and  fluid  contents,  in  some  cases  a  secretion  from  the  inner 
wall  of  the  sac  begins,  so  that  the  softening  cyst  becomes  a  secretion  or 
exudation  cyst,  and  thus  grows.  Any  tissue  rich  in  cells  may  be  trans- 
formed into  a  cyst  by  mucous  metamorphosis  of  the  protoplasm,  or,  as 
others  express  it,  by  separation  of  the  mucous  substance  through  cells 
without  any  connection  with  development  of  mucous  glands."  He  then 
goes  on  to  liken  the  process  by  which  fluid  spaces  are  created  in  chondro- 
mata  and  fibromata  to  the  formation  of  the  joints  in  the  limbs  of  the  foetus 
by  mucous  softening  of  the  cartilage  tissue,  of  which  the  bones  of  the 
limbs  are  formed.  Furthermore  he  declares,  that  "the  often  slit-shaped, 
smooth-walled  cysts  with  serous,  or  sero-mucous  contents  which  occur  in 
uterine  myomata,  are  possibly  enormously  dilated  lymph  spaces,"  a  view 
which  was  first  advanced  by  Cruveilhier. 

It  will  be  seen  that  the  term  cystic  degeneration  is  rather  loosely  applied 
to  this  affection,  for  the  fluid  collections  taking  place  are  rather  results  of 
liquefaction  than  of  true  cyst  development.  Nevertheless  I  shall  adhere 
to  its  use. 

Cystic  degeneration  affects  submucous  or  interstitial  fibroids  much  less 
frequently  than  those  which  are  subserous.  The  following  case  reported 
by  Dr.  Sims,  which  he  considers  one  of  this  degeneration  in  a  submucous 
fibroid,  is  worthy  of  citation.  It  is  described  by  him  in  these  words  :  "  I 
passed  a  trocar  into  it  at  its  lowest  point,  and  in  the  direction  of  its  long 
axis,  and  there  were  discharged  more  than  twenty  ounces  of  a  colored 
serum.  The  puncture  was  enlarged  for  two  inches  to  prevent  its  closing. 
There  was  at  once  a  sensible  diminution  in  the  size  and  tension  of  the 
abdomen.  The  discharge  kept  up  for  some  time  ;  and  this,  together  with 
occasional  injections  into  the  very  fundus  of  the  uterus,  with  the  liquor 
ferri  persulphatis,  diluted  with  three  or  four  parts  of  water,  arrested  very 
promptly  the  hemorrhages,  and  the  patient  was  dismissed  in  two  months 
in  a  very  comfortable  condition,  and  with  strength  enough  to  walk  six  or 
eight  miles." 

As  the  records  of  cases  of  fibro-cystic  tumors  are  not  very  commonly 
met  with  in  the  literature  of  this  subject,  I  shall  make  reference  to  a  few 
of  them.  Kiwisch1  described  one  which  filled  the  whole  pelvic  cavity, 
and  extended  as  high  as  the  ensiform  cartilage.  It  took  its  rise  from  the 
posterior  uterine  wall ;  had  as  its  base  a  fibroid  tumor  the  size  of  the  head, 
which  was  enveloped  in  uterine  substance  ;  and  weighed  forty-six  pounds. 
Cruveilhier2  mentions  a  similar  one.  Spencer  "Wells3  speaks  of  two  cases. 
In  one   the  tumor  was  connected  with   the  right  side  of  the  fundus  by  a 

'  Quoted  by  Klob,  op.  cit..  p.  182.  2  Klob,  op.  cit.,  p.  182. 

3  Diseases  of  Ovaries,  p.  354. 


554  FIBRO-CYSTIC    TUMORS    OF    THE    UTERUS. 

broad  band  ;  its  solid  portion  weighed  sixteen  pounds  ;  its  fluid  portion 
twenty-six ;  and  a  semifluid  material  four  pounds.  The  uterus  was  twice 
its  natural  size.  In  the  other  there  were  two  tumors,  both  of  which  had 
a  uterine  attachment,  and  consisted  of  solid  and  fluid  elements.  A  very 
striking  instance  of  this  affection  I  saw  submitted  to  operation  by  Dr. 
James  L.  Little  of  this  city.  The  tumor,  which  yielded  very  obscure 
fluctuation,  filled  the  entire  abdominal  cavity,  and  was  composed  of  a  net- 
work of  fibrous  tissue,  constituting  spaces  varying  in  size  from  that  of  an 
apple  to  that  of  a  cocoanut,  which  were  filled  with  colloid  material.  This 
growth  sprung  from  the  neck  of  the  uterus.  It  took  its  origin  from  the 
post-cervical  wall,  and  the  tumor  growing  from  this  pedicle  filled  the  whole 
abdominal  cavity,  and  was  before  operation  regarded  as  ovarian. 

Symptoms — Fibro-cystic  tumors  do  not  vary  in  symptoms  from  sub- 
peritoneal fibroid  growths  of  equal  size.     Like  them  they  produce — 

Displacements  of  the  uterus  ; 

Pressure  on  rectum  and  bladder ; 

Menorrhagia  in  some  cases. 

Physical  Signs The  uterus  is  usually  found  to  be  enlarged  from  excess 

of  nutrition  resulting  from  the  formative  irritation  due  to  the  propinquity 
and  connections  of  the  tumor,  and  to  be  elevated  and  lie  in  front  of  it. 
The  sensation  yielded  by  bimanual  manipulation  and  by  palpation  is  not 
that  of  a  hard,  solid,  and  resisting  mass,  but  an  obscurely  fluctuating  sen- 
sation is  discovered.  It  is  common  in  such  cases  to  find  a  certain  number 
of  examiners  inclining  to  the  theory  of  fluidity,  and  others  to  that  of 
solidity  in  the  growth.  If  an  explorative  tapping  be  practised  by  the 
hypodermic  syringe,  a  very  small  amount  of  fluid,  which  is  usually  viscid 
or  turbid,  will  be  withdrawn  from  some  places,  while  no  fluid  whatever 
will  appear  from  others,  and  if  a  trocar  or  a  large  needle  of  the  aspirator 
be  employed  a  quart  or  two  of  thick  straw-colored  fluid  may  be  drawn  off', 
leaving,  usually,  solid  elements  remaining.  In  rare  cases  of  large  uterine 
cysts  the  sac  may  be  entirely  emptied,  and  even  these  signs  be  wanting. 

Differentiation Many  competent  authorities  have  declared  that  the 

diagnosis  of  this  form  of  tumor  and  its  differentiation  from  ovarian  cyst  is 
impossible.  Kceberle  says,  "  the  diagnosis  of  fibro-cystic  tumors  has,  up 
to  the  present  time,  been  declared  impossible  by  almost  every  author," 
and  Baker  Brown  acknowledges  that  he  knows  of  "  no  distinguishing 
marks  between  the  two."  Even  after  incision  Spencer  Wells  declares 
that  he  knows  of  nothing  but  a  darker  hue  of  the  sac-wall  to  put  the 
operator  on  his  guard.  The  result  of  this  difficulty  is  illustrated  by  the 
fact  that  out  of  Lee's  nineteen  cases  eighteen  were  operated  on  under  a 
mistaken  diagnosis  of  ovarian  cyst. 

The  conditions  with  which  this  form  of  tumor  will  most  likely  be  con- 
founded are — 


DIFFERENTIATION.  555 

Pregnancy ; 

Fibroid  tumor  of  the  uterus; 
Ovarian  cyst. 
From  the  first  it  may  be  known  by  absence  of  the  gastric  and  mammary 
symptoms  of  that  condition,  by  menstruation  not  only  continuing  but  per- 
haps showing  a  tendency  to  increase  in  amount  and  frequency,  by  absence 
of  foetal  movements  and  heart  sounds,  and  by  the  duration  of  the  tumor 
beyond  nine  months. 

From  fibroid  tumor  it  may  be  known  by  its  yielding  obscure  fluctuation, 
its  assuming  usually  larger  proportions,  its  more  rapid  growth,  and,  be- 
yond everything  else,  by  its  yielding  fluid  to  the  exploring  trocar. 

From  ovarian  cyst  diagnosis  is  usually  difficult  and  often   impossible ; 
the  chief  grounds  upon  which  it  will  always  depend,  and  upon  which  it 
may  sometimes  be  made,  are  the  following: — 
Shape  and  density  of  the  tumor  ; 
Its  connection  with  the  uterus  ; 
The  depth  of  the  uterus  ; 
The  rapidity  of  growth  and  effect  on  health ; 
The  effects  of  tapping  ; 
The  characters  of  the  fluid  withdrawn  ; 
The  elevated  position  of  the  uterus  in  the  pelvis. 
There  are  other  differential  signs,  but  these  are  the  really  reliable  ones. 
A  great  array  of  symptoms  often  confuses  rather  than  helps  the  inexpe- 
rienced diagnostician,  and  I  wish  to  analyze  the  subject  here  as  it  should 
be  analyzed  at  the  bedside. 

"When  a  differential  diagnosis  is  arrived  at,  it  is  ordinarily  done  in  the 
following  way : — 

1st.  The  examiner  in  palpating  has  been  struck  by  the  fact  that  the 
surface  of  the  tumor  which  he  supposes  to  be  ovarian  is  peculiarly  irregu- 
lar and  resisting  to  the  touch,  and  that  fluctuation  is  obscurely  yielded  in 
certain  places  only.  This  renders  him  suspicious,  and  he  determines  to 
investigate  fully  before  committing  himself  to  the  diagnosis  of  ovarian 
tumor  which  at  first  suggested  itself. 

2d.  He  now  examines  the  uterus  and  finds  that  the  sound  proves  it  to 
be  much  deeper  than  normal ;  that  as  he  rotates  this  organ  upon  the 
sound  it  appears  united  to  the  tumor  ;  that  posteriorly  to  the  uterus  the 
tumor  seems  to  join  it  and  grow  from  it ;  and  that  as  an  assistant  lifts, 
depresses,  and  rolls  the  tumor,  the  uterus  moves  distinctly.  His  suspi- 
cions are  strengthened. 

3d.  He  now  questions  the  patient  more  closely,  finds  that  she  is  over 
thirty,  fibro-cystic  tumors  rarely  appear  before  thirty,  and  that  this 
tumor  has  been  slowly  but  steadily  growing  for  four  or  five  years  without 
materially  impairing  her  health.  He  feels  the  necessity  for  further  infor- 
mation, and  resorts  to  removal  of  the  fluid  by  the  aspirator  or  trocar. 


556 


FIBRO-CYSTIC    TUMORS    OF    THE    UTERUS. 


4th.  The  fluid  which  pours  away  is  transparent  and  straw-colored,  and 
as  it  ceases  to  flow  he  discovers  that  the  sac  only  in  part  collapses.  Test- 
ing the  matter,  he  finds  that  this  is  not  due  to  the  existence  of  other  cysts, 
but  that  solid  elements  prevent  collapse. 

5th.  He  now  examines  the  fluid  withdrawn,  and  finds  that  it  coagulates 
spontaneously  as  well  as  under  heat.  The  whole  contents  of  the  tube  give 
a  large  coagulum  like  that  of  the  blood  clot  in  consistence  though  not  in 
color.  Placed  under  the  microscope,  a  peculiar  fibre  cell  may  be  dis- 
covered which  is  characteristic,  according  to  Dr.  Atlee,  of  the  fluid  of  fibro- 
cystic and  not  of  ovarian  tumors.  It  is  a  product  derived  from  the  tissue 
in  which  the  cyst  forms  itself,  the  muscular  tissue  of  the  uterus. 


Fig.  224. 


The  flhre  cell  (A)  characteristic  of  fibro-cystic  tumors.     (Atlee.) 

6th.  Anxious  now  to  test  as  completely  as  possible  the  relation  of  tumor 
and  uterus,  he  practises  the  method  of  Ilegar  and  Schultz.  The  patient 
is  anaesthetized  and  laid  upon  the  back  ;  one  assistant  pulls  the  cervix 
down  by  means  of  a  tenaculum,  and  another  seizes  the  tumor  and  alter- 
nately lifts  and  depresses  it,  while  the  examiner,  by  means  of  two  fingers 
carried  high  up  the  rectum,  seeks  to  find  out  how  intimate  is  the  relation 
of  uterus  and  tumor. 

Even  from  this  apparently  copious  supply  of  diagnostic  means  in  many 
cases  only  a  doubtful  conclusion  can  be  drawn,  for  every  one  of  them  is 
often  fallacious  in  typical  cases,  and  always  so  in  large  cysts  unaccompa- 
nied by  any  fibrous  structure  except  that  constituting  their  walls.  The 
tumor  may  not  be  irregular  nor  hard;  it  may  develop  with  great  rapidity  ; 
the  uterus  may  not  increase  in  depth,  may  move  independently  of  the 
tumor;  and  tapping  may  empty  it.  On  the  other  hand,  cases  of  true 
ovarian  tumor  are  not  rarely  met  with  in  which  the  uterus  is  increased  in 
depth,  the  tumor  and  uterus  move  synchronously  under  slight  impulse, 
tapping  only  partially  empties  the  sac,  leaving  solid  masses  remaining,  and 


TREATMENT.  557 

the  growth  of  the  tumor  is  slow  and  has  little  influence  upon  the  general 
health.  The  late  Dr.  W.  L.  Atlee1  most  truly  remarked,  that  "  no  amount 
of  experience  will  avail  the  surgeon  in  making  a  differential  diagnosis  by 
the  ordinary  methods  of  examination."  "  But,"  said  that  eminent  ova- 
riotomist  in  alluding  to  his  past  errors  of  diagnosis,  "  such  errors  need 
not  be  repeated."  He  believed  that  we  had  arrived  at  a  period  when,  by 
means  of  the  fibre  cell,  diagnosis  becomes  at  once  simple  and  positive. 
Should  the  diagnostic  method  which  he  has  furnished  us  bear  the  test  of 
experience,  a  most  important  result  will  indeed  have  been  attained.  Dr. 
Atlee  relies  upon  the  physical  properties  of  the  fluid  withdrawn  from  these 
sacs  for  diagnosis  of  their  origin,  whether  uterine,  ovarian,  or  of  the  broad 
ligaments.  The  characters  of  fibro-cystic  fluid  are  these.  It  is  transpa- 
rent, of  a  deep  amber  color,  and  very  thin  when  first  drawn,  but  forms  a 
hard  and  firm  coagulum  in  a  little  while,  which  in  a  few  hours  shrinks  and 
separates  into  a  clot  and  a  thin  watery  serum.  It  coagulates  by  heat,  and 
resembles  in  every  respect  the  liquor  sanguinis.  Under  the  microscope 
few  cells  appear  in  it.  There  are  epithelium,  oil  globules,  and  a  fibre  cell, 
represented  at  A  in  Fig.  224.  This  is  characteristic  of  the  structure  in 
which  the  cyst  originated. 

Course,  Duration,  and  Termination This  form  of  tumor  runs  a  very 

slow  course.  Much  graver  and  more  rapid  in  development  than  the  pure 
fibroid,  it  develops  more  slowly  than  ovarian  cyst.  I  had  recently  under 
observation  two  very  large  tumors  supposed  to  be  of  this  kind.  One  of 
them  had  existed  for  eleven  years,  and  yet  the  patient  still  performed  the 
functions  of  nurse  in  a  hospital.  It  is  true  that  her  abdomen  was  im- 
mensely distended,  and  that  she  moved  about  with  difficulty,  but  thus  far 
she  had  not  been  completely  incapacitated.  In  the  second  case  the  tumor 
had  existed  for  about  five  years.  It  was  quite  large,  when  the  patient, 
after  an  attack  of  illness  which  was  supposed  by  her  physician  to  be  peri- 
tonitis, began  to  improve,  and  is  now  reported  to  me  as  being  better  than 
she  has  been  for  many  years. 

Although  this  is  the  slow  course  of  the  affection  in  some  cases,  in  others 
it  exhausts  the  patient  by  constitutional  irritation,  the  result  of  mechanical 
interference  with  other  organs;  menorrhagia ;  and  deprivation  of  exercise 
and  fresh  air. 

Prognosis — The  prognosis  is  unfavorable.  Relief  by  medication  is  in 
the  present  state  of  therapeutics  unattainable,  and  the  operation  of  lapa- 
rotomy is  much  less  promising  when  performed  for  uterine  than  for  ova- 
rian tumors. 

Treatment Nothing  more  need  be  stated  in  reference  to  this  subject 

than  has  been  already  said  in  connection  with  uterine  fibroids,  and  will  be 
said  in  speaking  of  ovariotomy. 

1  Ovarian  Tumors,  p.  263. 


558  UTERINE    POLYPI. 


CHAPTER    XXXVI. 

UTERINE  POLYPI. 

Definition — A  uterine  polypus  is  a  tumor  covered  by  the  mucous  mem- 
brane of  the  uterus,  attached  to  that  organ  by  a  pedicle  or  stem,  and 
originating  in  a  hypertrophy  or  hyperplasia  of  some  of  its  proper  tissues. 
Portions  of  placenta,  the  fibrinous  remains  of  blood  clots,  and  parts  of  the 
fetal  envelopes,  sometimes  remain  in  utero,  and  take  upon  themselves  the 
shape  and  develop  the  symptoms  of  true  polypi.  They  might,  with  justice, 
be  described  as  pseudo-polypi,  but  the  true  polypus  originates  in  morbid 
growth  of  the  tissues  of  the  organ  from  which  it  springs,  and  it  retards 
progress  in  pathology  to  confound  these  conditions  with  that  to  which  this 
chapter  is  devoted. 

History — While  so  many  uterine  disorders  of  great  obscurity  are  de- 
scribed by  the  earliest  medical  writers,  this,  the  diagnosis  of  which  is 
often  so  self-evident  and  positive,  attracted  little  attention.  Hippocrates, 
Celsus,  Galen,  and  even  Aetius  make  no  mention  of  it.  By  Moschion 
it  was  described  in  the  third  century,  and  called  pulps  or  polypus,  but  it 
was  certainly  neither  well  understood  nor  treated  in  his  time,  and  we  get 
no  clear  accounts  of  it  until  the  revival  of  this  branch  of  learning  by  the 
French  School  in  the  seventeenth  century.  Then  Guillemeau,  and  subse- 
quently Levret,  threw  much  light  upon  it,  and  in  the  latter  part  of  the 
eighteenth  and  beginning  of  the  nineteenth  centuries  many  others  contri- 
buted to  place  our  knowledge  upon  its  present  basis. 

Varieties. — The  student  will  meet  with  much  difficulty  in  arriving  at 
definite  ideas  concerning  the  varieties  of  uterine  polypi.  Almost  all 
authors  differ  in  their  classification,  and  the  number  of  names  which  have 
at  various  times  been  applied  to  them  is  too  large  even  for  repetition. 
Let  it  be  borne  in  mind  that,  since  these  tumors  are  formed  by  excessive 
development  of  one  of  the  tissues  existing  in  the  uterus,  there  are  but  three 
elements  which  can  give  rise  to  them  :  the  muscular  tissue  ;  the  connective 
tissue  ;  or  the  glands  of  the  organ.  It  is  true  that  by  some  a  species  of 
vascular  polypus  formed  from  development  of  the  bloodvessels,  a  species 
of  telangiectasis,  has  been  described,  but  it  is  probable  that  this  is  only  a 
form  of  the  cellular  or  mucous  variety.  All  classifications  of  these  growths 
are  to  a  great  extent  arbitrary,  and  hence  in  the  present  state  of  pathology 
none  can  become  universal.     That  which  I  shall  adopt  is  this: — 

1st.  Cellular     polypi; 

2d.  Glandular       " 

3d.  Fibrous  " 


PATHOLOGICAL    ANATOMY, 


r>59 


Fig.  225. 


These  varieties  are  subjeet  to  morbid  changes  which  create  other  forms  ; 
as,  for  example,  fatty,  calcareous,  and  malignant  polypi.  Colombat  refers 
to  a  large,  hollow  polypus  which,  when  removed,  leads  the  operator  at 
first  to  fear  that  he  has  mistaken  an  inverted  uterus  for  a  polypus.  He 
states  that  Kicherand  and  Jules  Cloquet  were  once  thus  deceived,  until 
the  subsequent  death  of  the  patient  enabled  them  to  correct  their  error  by 
post-mortem  inspection.  Mine.  Boivin  represents  one  of  this  character, 
in  Plate  19  of  her  work.  She  calls  it  a  hollow  polypus; 
declares  that,  before  its  removal  by  M.  Dubois,  it  was 
regarded  as  inversion  by  several  physicians,  and  ac- 
counts for  it  by  supposing  that  some  plastic  element 
had  coated  the  uterus  and  been  ripped  off,  except  at 
its  cervical  attachment,  and  had  become  inverted  by 
menstrual  fluid  collected  above.  Some  years  ago  Dr. 
Henschel  presented  to  the  New  York  Obstetrical 
Society  a  hollow  polypus  which  was  attached  to  the 
cervix  by  three  points.  It  was  referred  to  Dr.  Noeg- 
gerath  for  examination  and  report,  and  his  method  of 
accounting  for  it  was  similar  to  that  of  Mme.  Boivin 
in  the  case  just  mentioned. 

Pathological  Anatomy The  cellular  polypus  is  a 

tumor,  generally  of  pear  shape,  varying  in  size  from  a 
marble  to  a  hen's  egg.  It  is  covered  over  by  mucous 
membrane,  and  consists  within  of  connective  tissue  in 
a  state  of  hypertrophy  or  hypergenesis.  Its  attach- 
ment is  generally,  though  not  always,  to  one  wall  of  the  cervix,  and  in  its 
structure  there  appears  a  certain  amount  of  cervical  fibrous  tissue.  Some- 
times the  pedicle  of  this  variety  is  very  long  and  slender,  so  that  it  hangs 
outside  of  the  vulva. 

The  glandular  polypus  consists  in  hypertrophy  of  the  Nabothian  glands, 
or,  according  to  Dr.  Farre,  of  the  utricular  follicles.  Several  follicles  are 
enlarged,  and,  being  bound  together  by  connective  tissue,  make  up  a  tumor 
of  pediculated  form.  It  may  arise  either  from  the  cervix  or  body,  but 
very  generally  grows  from  the  former,  and  is  commonly  gregarious,  a 
large  number  of  very  small  ones  often  studding  the  walls  of  the  cervical 
canal.  The  most  remarkable  instance  of  this  variety  with  which  I  have 
ever  met  is  that  represented  in  Fig.  226.  The  whole  growth  measured  in 
length  4|  inches,  and  in  longest  diameter  2|  inches.  It  filled  the  vagina 
completely,  grew  from  the  inner  wall  and  lip  of  the  cervix,  caused  no  symp- 
tom except  leucorrhoea  and  pelvic  neuralgia,  and  was  not  known  to  exist 
until  difficulty  in  sexual  intercourse  caused  the  patient  to  apply  for  exami- 
nation. The  mass  was  examined  after  removal  by  Dr.  F.  Delafield,  and 
found  to  consist  of  enlarged  cervical  follicles,  the  grape-like  masses  shown 
in  the  diagram,  which  was  copied  from  nature  by  Dr.  J.  B.  Hunter,  bound 


Cellular  polypus. 


500 


UTERINE    POLYPI, 


together  by  connective  tissue.     I  removed  it  with  great  ease  by  the  ecra- 


The  fibrous  polypus   is  a  submucous   fibroid,  resembling  closely  those 

which  are  subserous  and  interstitial. 
Slowly  extruded  from  the  uterine 
parenchyma  by  its  contraction,  the 
tumor  gradually  acquires  a  pedicle 
and  becomes  the  form  of  polypus 
under  consideration.  Fibrous  po- 
lypi usually  arise  from  the  body  of 
the  uterus,  though  they  are  some- 
times attached  to  the  rim  of  the  os. 
Causes — Any  chronic  inflamma- 
tory action,  any  obstruction  to 
escape  of  menstrual  blood  which 
causes  uterine  tenesmus,  or  any 
influence  tending  to  keep  up  ute- 
rine congestion,  will  predispose  to 
hypergenesis  of  the  elements  of  the 
mucous  membrane.  But  as  for 
fibroids,  so  for  fibrous  polypi,  no 
positive  cause  is  known. 

Symptoms Polypi  occasion  two 

classes  of  symptoms;  one  dependent 
upon  the  congestion  which  their 
presence  excites,  the  other  upon  the 
mechanical  obstruction  which  they 
offer  to  the  escape  of  menstrual 
blood.  These  two  influences  result 
in  the  following  signs: — 

Leucorrhcea ; 

Pain  in  back  and  loins; 

Menorrhagia ; 

Metrorrhagia ; 

Hydrorrhea ; 

Dysmenorrhoea. 
The  last  of  these  is  not  a  fre- 
quent sign,  but  sometimes  presents 
itself  prominently,  as  it  did  in  the 
following  case,  which  occurred  be- 
fore we  understood  the  use  of  tents 
as  we  do  at  present.  A  lady  came 
,     .  „.    ,. .  .  .  ...    ,.  from  a  distance  to  put  herself  under 

A  submucous  fibroid  being  gradnally  trans-  I 

formed  into  a  fibrous  poiypu».  Dr.  Metcalfe's  care  for  dysmenor- 


Glandular  polypus. 


Fifl.  227. 


DIFFERENTIATION.  501 

rhoea,  characterized  by  severe  tenesmus  and  expulsion  of  clots.  These 
symptoms  had  lasted  for  years,  and  had  resulted  in  emaciation,  and  great 
nervousness  and  irritability.  In  time  she  came  under  my  care,  was  treated 
by  me  for  nearly  a  year,  and  went  home  unrelieved.  At  her  next  menstrual 
period  she  sent  for  the  physician  of  the  neighborhood,  who  examined  by 
touch,  detected  in  the  vagina  a  small  polypus  which  hung  by  a  stem  from 
the  uterus,  and  twisted  it  off,  to  her  complete  and  permanent  relief.  This 
had  been  at  last  expelled  after  having  rested  upon  the  os  internum,  and 
acted  as  a  ball  valve  for  years.  The  uterus  had  been  repeatedly  examined 
before,  but  nothing  could  be  discovered. 

Physical  Signs These  will  depend  in  great  degree  upon  the  size  and 

location  of  the  growth.  Should  it  be  in  the  cavity  of  the  body,  and  small, 
no  signs  will  be  afforded  by  the  touch  or  speculum,  and  the  uterine  sound 
will  give  no  evidence  of  its  presence.  The  cavity  will  be  discovered  to 
be  much  congested,  and  a  copious  flow  of  blood  will  often  follow  the  with- 
drawal of  the  instrument.  Should  the  tumor  be  large,  the  uterus  will 
often  be  found  to  be  displaced,  and  increased  in  size,  and  the  cervix  some- 
what dilated.  Should  the  attachment  of  the  tumor  be  cervical,  it  can 
often  be  felt  hanging  from  the  canal  or  in  the  os  uteri.  But  no  examina- 
tion for  uterine  polypi  can  be  considered  complete  until  the  cervix  has 
been  fully  dilated  by  tents,  and  careful  exploration  been  made  by  touch. 
Even  then  small  growths  will  sometimes  escape  research. 

By  any  other  means  than  dilatation  and  touch  it  is  often  very  difficult 
to  determine  whether  a  small  neoplasm  exist  in  utero  or  not.  This  state- 
ment, the  history  of  the  following  cases  which  have  occurred  in  my  prac- 
tice very  recently,  will  illustrate  : — 

Miss  B.,  a  spinster,  aged  thirty-eight  years,  had  suffered  from  profuse 
menorrhagia  and  metrorrhagia  for  three  years,  and  upon  examination  I 
found  the  uterus  enlarged  and  measuring  internally  four  inches.  I  made 
the  diagnosis  of  intra-uterine  neoplasm,  dilated  with  tupelo  tents,  and 
found  only  fungosities  to  exist. 

Mrs.  M.,  aged  thirty-seven  years,  married  thirteen  years,  sterile,  suffer- 
ing from  marked  dysmenorrhoea,  was  submitted  to  the  operation  of  bilateral 
tracheotomy,  on  account  of  constriction  and  tortuosity  of  the  neck,  which 
rendered  the  introduction  of  the  sound  almost  impossible.  On  the  tenth 
day  after  the  operation  hemorrhage  occurred,  and  upon  examination  I 
found  a  hard,  fibrous  polypus  as  large  as  a  pigeon's  egg  presenting  at  the 
os,  which  I  very  readily  removed. 

Differentiation Polypi  must  be  differentiated  from  fibrous  tumors  even 

after  the  discovery  of  an  intra-uterine  growth  has  been  made.  The  symp- 
toms to  which  these  affections  give  rise  are  very  similar,  and  it  is  by 
physical  means  alone  that  differentiation  can  be  effected.  These  means 
are  the  use  of  tents,  the  sound,  and  touch.  By  them,  the  mobility  of  the 
3G 


562  UTERINE    POLYPI. 

tumor,  the  point  of  its  attachment,  and  the  breadth  of  its  base,  may  usu- 
ally all  be  determined. 

Course  and  Termination Nature  may  cure  a  uterine  polypus  by  eject- 
ing the  mass  with  so  much  force  as  to  fracture  its  attachment  and  discon- 
nect it  from  the  uterus ;  or  calcification,  fatty  degeneration,  ulceration,  or 
sloughing  may  occur.  But  none  of  these  results  can  be  looked  for  with 
any  confidence.  In  the  majority  of  instances,  without  surgical  interference, 
steadily  advancing  anaemia  ultimately  destroys  life. 

Prognosis The   prognosis  is  generally  good ;    depending,  of  course, 

upon  the  possibility  of  removal. 

Complications — Polypi,  if  so  small  as  not  to  greatly  increase  the  weight 
of  the  uterus,  create  but  two  complications,  leucorrhoea  and  metrorrhagia, 
which  may  go  on  to  the  production  of  fatal  anaemia.  If  they  be  so  large 
as  to  increase  the  size  and  weight  of  the  uterus,  displacements,  with  their 
attendant  irritation  of  rectum  and  bladder,  may  show  themselves,  and  even 
inversion  has  been  known  to  occur. 

Treatment This  may  be  either  palliative  or  curative,  and  it  is  as  neces- 
sary for  the  practitioner  to  familiarize  himself  with  one  as  with  the  other 
plan.  Many  a  patient  suffering  from  intra-corporeal  polypus  has  had  life  cut 
short  by  intemperate  efforts  at  its  removal,  who  by  a  systematic  and  patient 
course  of  palliative  treatment  might  not  only  have  lived  for  years  but  have 
ended  her  disease  by  expelling  the  tumor  into  the  vagina  and  rendering  it 
accessible  to  safe  removal.  There  are  few  men  of  large  experience,  who 
cannot  recall  such  instances  of  the  unfortunate  results  of  injudicious  prac- 
tice, either  in  their  own  experience  or  that  of  others.  The  dictum  of 
Gooch  that,  "  when  hemorrhages  from  the  uterus  arise  from  a  polypus, 
medicines  are  useless.  The  only  effectual  way  to  cure  the  hemorrhages  is 
to  remove  the  polypus,"  is  undeniably  sound.  Lives  have,  however,  been 
sacrificed  to  just  such  a  style  of  assertion  both  in  this  and  other  diseases. 
"When  the  young  practitioner  reads  the  brilliant  record  of  an  os  dilated,  an 
instrument  carried  to  the  fundus,  a  tumor  removed,  and  a  case  of  metror- 
rhagia cured,  he  feels  almost  culpable  if  he  have  a  case  under  treatment 
and  do  not  follow  a  similar  course,  and  as  he  sees  his  patient's  pale  face 
every  day  demanding  a  cure,  he  is  often  hurried  into  a  resolve  to  run  every 
risk  to  effect  one.  But  he  who  is  familiar  with  this  kind  of  practice  knows 
that  it  in  reality  involves  many  dangers,  and  that  successful  cases  have  a 
proneness  for  creeping  into  literature  which  does  not  characterize  fatal 
issues. 

I  would  be  distinctly  understood,  as  not  undervaluing  the  practice  of 
dilating  the  cervix  and  removing  intra-corporeal  polypi  by  instruments 
carried  to  the  fundus.  I  merely  desire  to  insist  upon  the  fact  that  such  a 
course  is  necessarily  dangerous  ;  that  it  should  be  undertaken  only  after 
careful  consideration  ;  and  that  its  proper  performance  requires  skill  and 
experience. 


TREATMENT.  563 

Whenever  it  is  practicable  to  do  so,  all  manipulation  should  be  delayed 
until  expulsion  of  the  tumor  into  the  vagina  is  accomplished ;  but,  unfor- 
tunately, operative  procedure  is  often  called  for  before  this  can  be  effected. 
Then  the  operator  has  no  choice.  He  is  forced  to  proceed  to  removal  of 
the  growth  even  at  a  disadvantage  and  at  a  risk  to  his  patient.  If  the  os 
internum  be  fully  dilated,  the  opening  of  the  external  os  will  not  prove 
diflicult  of  accomplishment.  Slitting  the  neck  or  dilating  it  will  usually 
be  sufficient  to  bring  the  growth  within  reach  of  a  tenaculum  which  will 
draw  it  forth.  But  where  both  are  to  be  opened  danger  is  involved  in  the 
process,  for  not  only  are  we  called  upon  to  assume  that  connected  with  and 
dependent  upon  the  use  of  tents  :  we  have  to  do  so  in  a  pathological  con- 
dition peculiarly  liable  to  be  complicated  by  endometritis  and  pelvic  peri- 
tonitis. I  have  seen  several  deaths  due  to  these  efforts,  and  I  always 
inaugurate  them  with  a  certain  amount  of  anxiety. 

Palliative  Treatment As  I  have  said  a  great  deal  in  connection  with 

the  treatment  of  submucous  fibroids,  which  would  have  to  be  repeated  here 
if  I  went  into  the  detailed  consideration  of  this  subject,  I  shall  limit  my- 
self to  a  concise  recapitulation. 

1st.  Replace  the  uterus  if  it  be  displaced,  and  keep  it  in  position  by 
means  of  an  appropriate  pessary,  at  the  same  time  that  all  pressure  is 
taken  from  the  fundus  by  avoidance  of  tight  clothing  and  all  violent  mus- 
cular efforts,  and  by  the  use  of  skirt  and  abdominal  supporters. 

2d.  Keep  the  patient  in  bed  at  menstrual  periods,  urging  her  to  avoid 
warm  drinks,  and  to  use  cold  and  acid  ones.  Give  viscum  album,  can- 
nabis indica,  opium,  gallic  acid,  ergot,  or  elixir  of  vitriol  freely  during 
the  periods.  After  a  menstrual  epoch  has  lasted  four  or  five  days,  use  a 
tampon  saturated  with  solution  of  alum  or  tannin,  removing  it  immediately 
if  there  be  any  evidence  of  regurgitation  through  the  tubes. 

3d.  Keep  the  bowels  regular,  and  avoid  fatigue  and  over-exertion  at  all 
times. 

4th.  Repair  the  damage  done  to  the  blood  by  nutritious  food,  and  that 
done  to  the  nervous  system  by  bitter  tonics  and  nervines,  avoiding  the 
use  of  iron  and  quinine,  which  increase  the  tendency  to  hemorrhage. 

5th.  During  the  inter-menstrual  periods  give  ergot  freely,  to  favor  ex- 
trusion of  the  growth. 

Curative   Treatment There  are   three  positions   in  which  a  polypus 

may  be  found  :  above  the  contracted  os  internum,  above  the  contracted  os 
externum,  or  in  the  vagina.  The  first  position  presents  the  gravest  diffi- 
culties in  the  management  of  these  cases,  the  second  presents  much  less 
serious  difficulties,  while  the  third  may,  with  our  present  appliances,  be 
almost  said  to  present  none. 

If  it  be  discovered  that  the  cervical  canal  has  been  dilated  by  the 
weight  and  wedge-like  action  of  the  polypus  aided  by  uterine  contraction, 
the  walls  of  the  cervix  may  be  slit  on  each  side  nearly  to  the  vaginal 


564  UTERINE    POLYPI. 

junction,  and  a  tenaculum  or  vulsellum  fixed  in  the  tumor  by  which  it 
may  be  drawn  out  of  the  uterus.  Or  by  means  of  tents  the  resisting  os 
may  be  dilated  so  as  to  admit  the  smallest  size  of  Molesworth's  dilator, 
and  by  this  further  expansion  may  be  effected.  After  this,  if  the  tumor 
can  be  seized,  it  may  be  drawn  out,  or  ergot  in  full  doses  may  be  given  to 
cause  its  expulsion.  If  it  be  found  necessary  to  seek  the  pedicle  at  or 
near  the  fundus,  it  may  be  severed  by  the  same  means  which  we  adopt  in 
case  the  tumor  hang  in  the  vagina,  namely — 

Excision  ; 

Torsion  and  traction ; 

Ecrasement ; 

The  galvano-caustic  wire ; 

The  spoon -saw. 
Should  the  pedicle  be  within  reach  of  knife  or  scissors,  it  may  be 
divided ;  or  if  higher  in  the  uterus,  the  polyptome  (Fig.  228)  may  be  em- 
ployed. Should  the  growths  be  so  small  as  not  to  be  susceptible  of  seiz- 
ure, they  may  be  scraped  from  their  attachment  by  a  large  steel  curette ; 
and  should  they  be  small  and  possess  slender  pedicles,  they  may  be  seized 
with  forceps  and  twisted  off.  Should  they  be  so  small  and  slippery  as  to 
defeat  this  plan,  or  should  they  be  numerous,  or  return  very  soon  after 
removal,  the  cervix  should  be  slightly  dilated,  cleansed  of  mucus  and 
blood,  and  thoroughly  painted  over  by  fuming  nitric  acid,  as  recommended 
by  Dr.  Lombe  Athill  in  disease  of  the  lining  membrane. 

Fig.  228. 


c 


G.T/EMANN  &.C0. 


Simpson's  polyptome. 

The  ligature,  once  so  popular,  should  never  be  employed ;  the  tardiness 
of  its  action,  and  the  fetid  discharge  which  it  excites,  rendering  it  objec- 
tionable and  dangerous.  Ecrasement  constitutes  sometimes  a  safe  and 
expeditious  operation.  Sometimes,  however,  great  difficulty  attends  the 
encircling  of  the  tumor  by  the  chain  of  the  instrument.  To  effect  this,  it 
is  often  necessary  to  encircle  the  mass  first  by  means  of  a  ligature  passed 
by  Gooch's  canulae,  and  then  to  draw  the  chain  into  position  by  tying  it 
to  the  end  of  this,  as  represented  in  the  chapter  on  fibroids.  Under  these 
circumstances  Hicks's  wire  rope  ecraseur  (Fig.  229)  constitutes  an  excel- 
lent substitute.  The  polyptome  of  Simpson  or  that  of  Aveling  often 
answers  a  good  purpose  in  these  cases. 

When  the  polypus  is  of  hard,  fibrous  character,  and  fills  the  uterus  so 
completely  that  the  pedicle  cannot  be  reached,  those  portions  which  are 
within  reach  may  be  cut  away  piecemeal  by  Nelaton's  forceps,  constructed 


TREATMENT.  565 

for  this  purpose,  or  by  ordinary  curved  scissors.  Dr.  Gooch  long  ago 
announced  that  when  a  ligature  was  applied  around  one  of  these  growths, 
that  part  above  as  well  as  below  its  constriction  often  died.  It  is  with  a 
hope  of  such  a  result  that  we  make  use  of  this  means.     I  have,  however, 

Fig.  229. 


O.TIEMANN  A. CO. 

Hicks's  wire  rope  ecraseur. 

cut  through  the  centre  of  a  fibrous  polypus  and  found  the  attached  portion 
continue  to  flourish  as  before  operation. 

When  a  large  fibrous  polypus  presents  its  pedicle  in  such  a  way  that  it 
can  be  encircled  by  the  galvano-caustic  wire,  this  instrument  may  be  em- 
ployed. It  not  only  cuts  without  the  application  of  force  through  the 
hardest  tissue,  but,  being  brought  to  a  white  heat  by  the  electric  current 
which  passes  through  it,  it  sears  the  open  vessels,  checks  hemorrhage,  and 
prevents  septicaemia. 

I  have  deemed  it  my  duty  to  place  before  the  reader  all  the  methods  at 
our  disposal  for  the  removal  of  these  neoplasms,  that  he  may  exercise  his 
choice  as  to  a  selection.  In  my  own  practice  I  have  given  them  all  up 
for  the  spoon-saw,  which  is  fully  described  under  the  head  of  uterine 
fibroids.  A  very  small  spoon-saw  will  readily  pass  through  a  partially 
dilated  os  internum  and  without  difficulty  slip  up  to  the  attachment  of  the 
polypus  and  sever  it  without  the  creation  of  hemorrhage,  while  it  is  kept 
in  a  state  of  tension  by  traction  upon  its  most  dependent  part  by  the  vul- 
sellum  forceps. 

Should  a  very  large  fibrous  polypus  have  escaped  from  the  uterine  cavity 
in  whole  or  in  part,  the  lowest  portions  should  be  cut  away  by  scissors, 
and  the  tumor  delivered  piecemeal. 

In  conclusion,  I  offer  a  resume  of  the  methods  of  treatment  recom- 
mended in  this  chapter. 

1st.  If  a  polypus  exist  in  utero  and  the  cervical  canal  be  firmly  closed, 
avoid  immediate  attempts  at  its  removal  unless  the  symptoms  be  so  grave 
as  to  make  that  course  advisable.  Temporize  by  employing  palliative 
means  until  dilatation  of  the  cervix  and  perhaps  expulsion  of  the  growth 
into  the  vagina  are  effected. 

2d.  To  facilitate  expulsion,  dilate  by  tents  or  incise  the  walls  of  the 
cervix  laterally  and  use  ergot  steadily,  either  internally  or  hypodermically. 

3d.   If  the  os  internum  be  fully  dilated,  remove  the  polypus  at  once,  for 


566  SARCOMA    AND    ADENOMA    OF    THE    UTERUS. 

the  operation  is  one  attended  by  little  danger  even  if  the  cervix  requires 
incision. 

4th.  If  the  cervix  be  dilated  and  the  tumor  be  in  ytero,  seize  it  with  a 
vulsellum  at  its  lowest  extremity,  and  make  a  cautious  but  rapid  attempt 
at  its  removal  by  torsion  and  traction.  Lengthy  manipulations  carried 
on  in  utero  are  always  very  hazardous. 

5th.  If  it  cannot  be  removed  in  this  way,  slide  up  along  the  wall  of 
the  tumor,  upon  which  steady  traction  is  made,  the  spoon-saw,  sever  the 
stem,  and  deliver  the  growth. 


CHAPTER    XXXVII. 

SARCOMA  AND  ADENOMA  OF  THE  UTERUS. 

History Scattered  through  medical  literature  may  be  found  descrip- 
tions of  a  tumor  growing  from  the  cavity  of  the  uterus,  which  appears  to 
occupy  a  middle  ground  between  myo-fibroma  on  the  one  hand  and  true 
cancer  on  the  other.  Presenting  in  many  respects  the  ordinary  physical 
aspects  of  benign  fibroid  growths  in  their  early  periods,  these  tumors 
demonstrate  a  marked  tendency  to  return  after  ablation.  Even  after 
repeated  and  thorough  removal,  they  again  and  again  recur,  and  in  many 
cases  their  real  character  is  in  this  way  discovered.  Another  peculiar  and 
dangerous  characteristic,  which  marks  their  difference  from  benign  fibroids, 
consists  in  their  tendency  to  throw  out  fungoid  growths,  which  show  a 
marked  tendency  to  undergo  molecular  death  and  disappear  by  ulceration, 
which  process  saps  the  vital  forces  of  the  patient  by  repeated  and  pro- 
longed hemorrhages,  and  by  opening  the  mouths  of  absorbent  vessels  for 
the  entrance  of  septic  elements  into  the  blood. 

The  clinical  features  of  such  growths  will  be  found  recorded  in  English 
literature  by  Callender,1  Hutchinson,2  Oldham,8  and  West,4  to  whose  inte- 
resting accounts  the  reader  is  referred.  Of  course  pathologists  were 
struck  by  these  two  facts  in  connection  with  such  tumors :  first,  their 
marked  tendency  to  return  after  ablation,  and  second,  the  absence  of 
micrographic  evidences  of  cancer  in  pathological  developments  showing 
many  of  the  features  of  malignancy.  Paget  grouped  them  under  three 
heads,  malignant  fibrous  tumors,  recurrent  fibroids,  and  myeloid  tumors, 
while  Lebert  described  them  under  the  name  of  fibro-plastic  tumors,  and 
Rokitansky   under  that  of  fasciculated  cancer.     Not   until  the   time  of 

1  Pathological  Transactions,  vol.  ix.  2  Ibid.,  vol.  viii. 

'  Wilks,  Pathological  Anatomy,  p.  404.        *  Op.  cit.,  art.  Recurrent  Fibroid. 


PATHOLOGY.  567 

Vircliow  were  they  described  under  the  old  and  previously  loosely  applied 
term  of  sarcoma.  This  pathologist  clearly  defined  the  disease  and  placed 
it  in  a  distinct  class,  apart  from  developments  somewhat  similar  in  clini- 
cal features,  but  some  of  which  were  entirely  benign  and  others  truly 
cancerous. 

Definition,  Frequency,  and  Synonyms. — "  Sarcoma,"  says  Virchow, 
"  is  for  me  a  production  easily  definable.  I  mean  by  it  a  growth  the  tissue 
of  which,  following  the  general  group,  belongs  to  the  connective  tissue 
series,  and  which  is  distinguishable  from  marked  varieties  of  the  groups 
of  connective  tissues  only  by  the  predominant  development  of  cellular 
elements."1  They  possess,  he  declares,  the  characters  of  incomplete,  rudi- 
mental,  or  embryonic  development,  and  not  those  of  perfect  tissue.  This 
peculiarity  existing  in  the  original  tumor  becomes  more  and  more  marked 
as  recurrence  takes  place  after  successive  removals. 

"Were  I  to  draw  my  deductions  from  my  own  experience,  I  would  say 
that  sarcoma  of  the  uterus  was  not  very  rare.  Many  cases  which  have 
been  regarded  as  cancer,  and  not  a  few  of  supposed  fatal  fibroid  tumor  or 
polypus,  have  been  unquestionably  of  this  affection.  Virchow,2  however, 
expresses  a  different  opinion.  "The  production  of  sarcoma  on  the  mucous 
lining  of  the  uterus,"  says  he,  "  is  often  spoken  of,  and  even  in  his  first 
work  Lebert  describes  a  fibro-plastic  polypus.  Nevertheless,  from  my 
observation  sarcoma  is  very  rare  at  this  point,  and  the  majority  of  tumors 
described  as  such  are  of  a  simply  hyperplastic  nature.  True  sarcoma, 
however,  does  originate  in  the  uterine  mucous  membrane  in  medullary 
form  difficult  of  recognition,  often  very  soft,  and  with  round  cells,  some- 
times with  all  the  characteristics  of  myo-sarcoma ;  the  tissue  may  become 
in  places  more  compact,  and  may  form  larger  masses,  and  attain  a  degree 
of  firmness  so  great  that  I  have  seen  the  best  diagnosticians  deceived  as 
to  the  nature  of  the  affection,  and  take  it  for  a  fibroid."  Before  my  atten- 
tion was  especially  called  to  this  subject,  I  confounded  such  cases  with 
medullary  cancer.  Since  that  time  I  have  met  with  many  cases  which, 
botli  from  clinical  and  microscopic  evidence,  I  am  forced  to  regard  as 
sarcomatous  developments.  None  were  confounded  with  simple  hyper- 
plastic growths,  as  Virchow  suggests,  for  all  ended  fatally. 

Pathology — Pathologists  have  commonly  confounded  sarcoma  of  the 
uterus  with  cancer.  The  reasons  for  this  are  probably  these  :  after  the 
former  begins  to  ulcerate,  it  resembles  the  latter  in  many  clinical  features, 
both  have  a  marked  tendency  to  return,  and  they  sometimes  unite  in  the 
same  tumor.  The  time  has  certainly  arrived,  however,  when  they  should 
be  separated  both  clinically  and  pathologically. 

1  Pathol,  des  Tumeurs,  par  R.  Virchow,  traduit  par  P.  Aronsohn,  vol.  ii.  p.  173. 

2  Op.  cit.,  vol.  ii.  p.  344. 


568  SARCOMA    AND    ADENOMA    OF    THE    UTERUS. 

Of  late  years  uterine  sarcoma,  as  a  disease  apart  from  cancer,  has  re- 
ceived careful  study  in  Germany,  excellent  reports  of  cases  being  furnished 
by  Ahlfield,  Hegar,  Winckel,  Gusserow,  Spiegelberg,  and  others. 

Unlike  myo-fibromata,  sarcomatous  tumors  have  no  capsules,  but  are 
immediately  connected  with  the  uterine  connective  tissue.  Virchow  de- 
clares that,  "  in  accordance  with  their  density,  sarcomata  may  be,  like 
all  morbid  tissues,  divided  into  two  groups :  soft  and  hard  sarcomata." 
As  the  disease  consists  merely  in  a  multiplication  of  normal  cells,  homolo- 
gous to  the  tissue  in  which  it  develops,  and  subject  to  no  other  disorder 
than  hypertrophy,  it  is  characterized  by  one  of  the  cells  typical  of  the  con- 
nective tissue  group.  Thus  wre  may  have  spindle,  round,  and  stellate 
celled  sarcoma,  the  second  being  the  most  frequent,  and  the  first  the  rarest 
in  the  uterus.  In  some  cases  the  cells  are  so  large  as  to  cause  the  name 
"giant-celled"  to  be  given  to  the  growth.  "We  may,"  says  Virchow, 
"divide  all  sarcomata,  and  not  simply  those  rich  in  cells,  into  two  groups: 
the  one  with  large,  and  the  other  with  small  cells."  These  cells  are 
merely  exaggerated  reproductions  of  those  of  the  mother  tissue,  and  "be- 
have like  cells  of  parenchyma,  not  like  surface  cells  (epithelium,  cancer)," 
which  are  heteroplastic  to  the  mother  tissue.  Between  these  cells  the 
intercellular  substance  is  always  preserved,  while  in  cancer  we  find  cells 
of  epithelial  type  pressed  closely  together  in  alveoli  formed  of  trabecular 
created  by  connective  tissue. 

Sarcoma,  usually  primary,  is  sometimes  engrafted  upon  myo-fibroma  by 
the  process  styled  metaplasia,  and  a  true  sarcomatous  tumor  may  itself  be 
affected  by  cancer.  Sarcomata  into  which  a  great  deal  of  fibrous  tissue 
enters  are  dense,  like  myo-fibroma,  and  Hegar1  admits  a  transition  form, 
a  fibro-  and  myo-sarcoma.  Schroeder  gives  an  illustration  representing  a 
sarcomatous  polypus  growing  from  a  carcinomatous  cervix. 

Virchow  divides  all  sarcomata  into  hard  and  soft  in  a  general  way,  and 
then  gives  a  great  many  subdivisions,  as  fibro-sarcoma,  myxo-sarcoma, 
glio-sarcoma,  melano-sarcoma,  chondro-sarcoma,  and  osteo-sarcoma. 

These  growths  are  so  rich  in  vessels  that  Virchow  declares  that  this 
feature  is  characteristic  of  them.  To  this  vascularity  is  due  their  tendency 
to  give  forth  a  watery  flow,  to  bleed  freely,  and  to  absorb  septic  materials. 

Clinically,  uterine  sarcoma  presents  itself  under  two  forms,  which  are 
often  very  distinct  from  each  other,  and  yet  between  which  in  many  cases 
an  absolute  line  cannot  be  drawn.  These  are  the  hard  and  diffuse  forms. 
In  the  one  case  a  dense,  solid,  tense,  and  elastic  tissue  is  presented  to  the 
touch,  the  chief  anatomical  character  of  which  is  the  existence  of  fusiform 
cells.  In  the  other  a  diffuse,  a  fungous-like  structure  is  found,  which  is 
characterized  by  small  round  cells.  "When  the  parenchyma  of  the  uterus 
is  affected  by  the  hard  variety,  pain,  according  to  my  experience,  is  very 

1  Archiv  fur  Gynsekologie,  ii.  1871. 


PHYSICAL    SIGNS.  569 

severe.  When  a  purely  diffuse,  endometrial  form  of  the  disease  exists, 
there  is  very  often  none.  The  second  variety  will  sometimes  fill  and  dis- 
tend the  uterus  to  a  great  degree.  The  growth  being  removed  by  the 
curette,  the  patient  greatly  improves,  but  very  soon  the  uterus  refills  and 
operative  procedure  is  again  called  for.  I  have  known  patients  live  very 
comfortably  for  years  through  the  relief  afforded  by  this  course,  ultimately 
dying,  however,  of  the  continually  returning  affection. 

Causes. — With  reference  especially  to  uterine  sarcoma,  little  can  with 
positiveness  be  said  on  this  point.  Virchow  alludes,  in  speaking  of  sar- 
coma in  general,  to  injuries,  youth  and  old  age,  primitive  debility  in  the 
part  affected,  inflammations,  etc. ;  but  whether  uterine  sarcoma  has  ever 
been  traced  to  these  I  do  not  know. 

Symptoms These  may  be  thus  presented: — 

Pain  ; 

Menorrhagia  or  metrorrhagia ; 

Offensive  mucous  discharge  ; 

Pinkish  watery  discharge  ; 

Discharge  of  shreds  or  portions  of  the  tumor  ; 

Pressure  on  rectum  and  bladder  ; 

Uterine  tenesmus  ; 

Constitutional  depreciation. 
Gusserow  declares  that  pain  is  constant  and  early,  but  Hegar  denies 
this.     My  experience  would  lead  me  to  indorse  the  opinion  of  the  latter, 
though  I  have  seen  it  very  severe. 

Physical  Signs These  will  depend  to  a  certain  degree  upon  tike  indi- 
vidual peculiarities  of  the  case.  Sarcoma  usually  develops  in  the  cavity 
of  the  uterus.  One  case  has  been  reported  by  Veit  in  which  the  cervix 
was  primarily  affected,  two  by  Kunert,  and  I  have  now  under  my  care  an 
unquestionable  case  of  fibro-sarcoma  having  this  origin.  The  growth 
usually  arises  from  the  uterine  wall  by  a  broad  base  and  projects  into  the 
cavity.  In  time,  uterine  contractions  dilate  the  cervix,  and  a  portion  of 
the  mass  is  forced  through  the  os. 

In  rare  cases  sarcoma  assumes  a  polypoid  form,  and  in  others,  coinci- 
dently  with  the  uterine  development,  an  extra-uterine  growth  projects 
into  Douglas's  pouch  or  one  iliac  fossa.  Another  way  in  which  sarcoma 
affects  the  uterus  is  by  diffuse  infiltration  into  one  or  both  walls.  This 
may  affect  mucous  or  submucous  tissues  alone,  or  even  the  muscular  struc- 
ture itself.  This  surface  soon  ulcerates  and  gives  forth  a  fetid  discharge. 
In  some  cases  this  diffuse  infiltration  may  affect  the  whole  uterus,  giving 
it  the  appearance  of  symmetrical  enlargement. 

If  the  tumor  can  be  touched,  it  is  usually  found  to  be  soft,  spongy,  and 
friable,  though  in  some  cases  it  is  hard  and  firm  like  myo-fibroma.  By 
conjoined  manipulation  the  uterus  is  found  to  be  large  and  usually  irregu- 
lar in  shape  as  if  the  seat  of  fibroid  tumors.     The  uterine  sound  indicates 


570  SARCOMA    AND    ADENOMA    OF    THE    UTERDS. 

enlargement  of  this  organ.  It  is  very  common  for  the  cervix  to  be  dilated 
and  portions  of  the  mass  to  be  expelled. 

Differentiation — Although  these  symptoms  and  physical  signs  will 
strongly  point  to  the  existence  of  sarcoma,  the  microscope  alone  will  dis- 
tinguish it  from  cancer,  myo- fibroma,  and  simple  hyperplastic  growths. 

Course,  Duration,  and  Termination It  runs  a  much  slower  course 

than  true  cancer;  a  much  more  serious  one  than  fibroids  and  hyperplastic 
growths.  In  rare  cases  it  terminates  rapidly,  but  it  has  frequently  been 
known  to  last  for  five  or  six  years.  The  patient  gradually  sinks  under 
the  following  morbid  influences:  hemorrhage,  septicaemia,  spread  of  the 
disease  to  neighboring  abdominal  viscera,  disturbance  of  nutrition,  or 
peritonitis. 

Prognosis. — This  is  invariably  unfavorable  ;  a  fatal  issue  is  a  question 
merely  of  time,  whether  the  growth  be  removed  or  left  uninterfered  with. 

The  microscope,  to  a  certain  extent,  aids  us  in  predicting  the  probable 
rapidity  of  the  affection.  The  more  nearly  it  approaches  a  hard  growth, 
the  preponderating  element  of  which  is  fibrous  tissue,  the  slower  will  be 
its  course;  the  more  it  partakes  of  a  soft  character  and  shows  itself  rich 
in  cellular  elements,  the  more  rapid  will  be  its  progress  in  molecular 
death.  Again,  the  small-celled  varieties  show  a  more  marked  tendency  to 
rapidity  of  production  than  those  which  are  characterized  by  large  cells. 

Treatment If  the  cervix  be  dilated,  and  a  sessile  growth  be  discovered 

in  the  uterine  cavity,  it  should  be  entirely  removed  by  the  spoon-saw, 
galvano-cautery,  eerasement,  or  the  large  curette,  and  the  base  of  the 
growth  thoroughly  cauterized  with  chemically  pure  nitric  acid.  If  the 
cervix  be  not  dilated,  this  may  be  accomplished  by  the  use  of  tents,  and 
the  disease  attacked  by  the  surgical  means  recommended. 

Should  the  disease  affect  the  parenchyma,  and  not  especially  the  endo- 
metrium, the  propriety  of  uterine  ablation  should  certainly  be  considered. 
The  fact  that  this  disease  is  much  less  liable  to  return  after  removal  than 
cancer  would  recommend  it  more  strongly  than  in  that  disorder;  and  if 
sarcoma  were  confined  to  the  uterus,  the  prospect  of  success  from  operation 
would  be  far  greater. 

Adenoma  of  the  Uterus The  lining  membrane  of  the  uterus,  in  addi- 
tion to  sarcoma,  cancer,  benign  fungosities,  and  polypoid  tumors,  is  some- 
times the  seat  of  adenoma,  a  disease  consisting  of  hypertrophy  of  its 
glandular  structure. 

This  affection  develops  the  same  symptoms  as  the  others  just  mentioned, 
chief  among  which  is  hemorrhage.  The  diagnosis  is  established  by  expo- 
sure of  a  portion  of  the  diseased  tissue,  removed  by  the  curette,  to  the 
microscope. 

The  treatment  of  adenoma  consists  in  entire  removal  by  the  curette, 
after  dilatation  of  the  cervical  canal,  and  the  application  to  the  surface, 
from  which  it  has  been  scraped,  of  fuming  nitric  acid. 


CANCER  OF  THE  UTERUS.  571 

It  has  a  marked  tendency  to  return,  though  much  less  so  than  sarcoma 
and  cancer.  This  fact  should  teach  us,  however,  the  lesson  that  in  dealing 
with  it  the  entire  endometrium  should  be  thoroughly  scraped  in  order  to 
prevent  the  rapid  generation  of  some  remaining  portion  of  the  growth. 

I  have  seen  but  one  unquestionable  case  of  this  disease,  and  in  this  the 
curette  during  a  period  of  four  or  five  years  was  used  very  thoroughly  four- 
teen times,  compound  tincture  of  iodine  and  nitric  acid  having  been  re- 
peatedly applied  after  its  use.  After  that  the  patient  entirely  recovered, 
and  has  now  remained  well  for  a  number  of  years. 

The  growths  removed  in  this  case  were  examined  repeatedly  by  Dr.  F. 
Delafield,  who  for  some  time  feared  malignancy,  but  finally  decided  that 
they  were  of  the  character  mentioned  above. 

Very  recently  I  have  seen  a  case  with  Dr.  Moller,  upon  which,  during 
seven  years,  he  has  repeatedly  employed  the  curette  for  an  abundant  and 
steadily  recurring  growth.  A  portion  of  it,  being  examined  by  Dr.  W.  H. 
Welch,  the  pathologist  of  the  Woman's  Hospital,  was  pronounced  to  be  a 
mixture  of  sarcoma  and  adenoma. 


CHAPTER  XXXVIII. 

CANCER  OF  THE  UTERUS. 

Definition — Between  cancer  of  the  uterus  and  the  same  affection  in 
other  parts  of  the  system  there  are  no  marked  differences.  As  in  other 
organs,  it  may  be  defined  as  a  disease  which  is  characterized  by  great  pro- 
liferation of  connective  tissue,  excessive  generation  of  cells  of  epithelial 
type,  and  marked  tendency  to  extension  to  neighboring  parts,  to  molecular 
death,  and  to  return  after  removal.  Waldeyer1  concisely  defines  cancer  as 
"  an  atypical  epithelial  neoplasm." 

History — M.  Becquerel  asserts  that,  "  in  spite  of  its  great  frequency, 
cancer  of  the  uterus  is  not  a  disease  of  which  the  history  has  been  long 
known."  That  it  was  not  understood  as  we  understand  it  to-day,  is  most 
true;  but  the  ancients  surely  had  a  certain  degree  of  knowledge  concern- 
ing its  clinical  features.  Hippocrates — de  Morbis  Mulierum — describes  it 
at  length,  declaring  it  to  be  incurable.  Archigenes  wrote  a  chapter  upon 
it,  describing  the  ulcerated  and  non-ulcerated  forms  and  the  peculiarities 
of  the  discharges.  His  article  is  preserved  by  Aetius,  who  entitles  it, 
"  De  Cancris  Uteri,"  and  is  copied  verbatim  by  Paul  of  ^Egina  without 
the  slightest  acknowledgment.     The  Arabians  likewise  were  familiar  with 

*  Billroth,  Surg.  Pathol.,  Am.  ed. 


572  CANCER  OP  THE  UTERUS. 

it,  Alsaharavius,  Haly  Abbas,  and  Rhazes  all  alluding  to  its  prognosis  and 
treatment  in  a  manner  which  leads  us  to  believe  that  they  understood  its 
true  nature. 

Upon  the  revival  of  gynecology  in  France,  the  disease  was  confounded 
with  fibrous  tumors  and  areolar  hyperplasia.  Astruc  described  "  scirrhus" 
as  the  result  of  abortion,  in  1766,  and  the  confusion  which  attached  to  his 
description  extended  long  after  him.  It  characterized  the  times  of  Reca- 
mier  and  Lisfranc,  and  even  so  late  as  our  own  period  we  see  the  view 
endorsed  by  Ashwell,  Montgomery,  Duparcque,  and  many  others.  Blatin 
and  Nivet,1  in  expressing  their  belief  that  scirrhus  results  from  chronic 
inflammation  of  the  parenchyma,  append  the  following  footnote :  "  Paul 
of  xEgina,  Galen,  Andral,  Broussais,  Breschet  and  Ferrus,  Piorry,  Bouil- 
laud,  etc.,  place  scirrhus  among  the  terminations  of  chronic  inflammation; 
some  of  them,  however,  admit  the  existence  of  a  predisposition."  Although 
it  was  known  to  the  physicians  of  the  most  ancient  times, 'we  are  indebted 
to  them  for  little  in  connection  with  it,  except  portions  of  the  imperfect 
nomenclature  which  now  attaches  to  it.  It  is  beyond  question  that  within 
the  last  half  century  much  more  has  been  accomplished  for  the  thorough 
understanding  of  the  subject  than  ever  has  been  done  at  any  former  time, 
and  yet,  even  now,  much  doubt  and  uncertainty  exist  as  to  its  varieties, 
and  its  pathological  characteristics. 

Pathology With  regard  to  the  pathology  of  cancer  the  views  of  patholo- 
gists have,  of  late,  undergone  considerable  modification.  Formerly,  the 
prevailing  opinion  was  that  it  was  always  the  local  manifestation  of  a 
general  blood  state.  At  present,  opinion  is  divided ;  many  still  adhering 
to  the  old  view,  while  others  are  yielding  to  the  cogent  reasoning  of  those 
who  regard  it  as  originally  a  local  affection,  one  of  the  most  striking  fea- 
tures of  which  is  a  tendency  rapidly  to  intoxicate  the  system.  In  an  ex- 
ceedingly able  and  interesting  discussion  upon  this  subject  before  the 
London  Pathological  Society  in  March,  1874,  the  former  of  these  views 
was  maintained  by  Messrs.  De  Morgan,  Hutchinson,  Moxon,  Arnott,  and 
others ;  the  latter  by  Sir  James  Paget,  Sir  W.  Jenner,  Dr.  Greenhow, 
and  others.  So  equally  was  the  society  divided  in  opinion  that  a  com- 
mentator remarks  that  "  in  point  of  numbers  the  constitutionalists  almost 
equalled  the  localists." 

"Whatever  be  the  peculiar  state  which  gives  rise  to  cancerous  deposit,  it 
is  certain  that  any  form  of  the  affection  may  arise  from  one  and  the  same 
disorder.  This  is  proved  by  the  facts  that  several  deposits  of  different 
varieties  may  coincidently  exist,  that  one  form  may  change  into  another, 
and  that  one  being  removed  by  surgical  means  a  different  one  may  re- 
place it. 

As  there  is  doubt  as  to  the  origin  of  cancer,  so  is  there  as  to  the  method 

1  Mai.  dos  Femmes,  Paris,  1842. 


VARIETIES.  573 

in  which  the  local  deposit  take3  place.  Certain  pathologists,  of  whom 
M.  Robin,  of  Paris,  may  be  taken  as  a  representative,  believe  that,  under 
the  influence  of  a  constitutional  vice,  which  exerts  a  baneful  influence 
over  nutrition  and  formation,  a  fluid  blastema  is  transmitted  from  the 
blood  into  the  connective  tissue  of  the  part.  From  this  molecules  arrange 
themselves  and  form  the  anatomical  elements  of  cancer.  Another  party, 
of  which  Virchow  was  the  founder,  maintains  that  the  proliferation  of 
connective  tissue  and  hypergenesis  of  cells  both  arise  from  repeated  sub- 
division of  connective  tissue  corpuscles.  These  go,  some  to  creation  of 
tissue,  some  to  filling  brood-spaces,  and  others  to  formation  of  epithelium. 
Still  another  party,  headed  by  Remak  and  Waldeyer,  hold  that  all  cancer- 
ous disease  in  the  uterus  takes  its  origin  from  the  epithelium  lining  glands 
which  dip  into  the  parenchyma.  The  cancer  cells  are  due  to  perverted 
action  of  normal  epithelial  production,  while  the  stroma  comes  from  pro- 
liferation of  the  interstitial  substance  or  connective  tissue  of  the  part. 
"Only  Thiersch,  and  recently  "VValdeyer,"  says  Billroth,  "maintain,  as  I 
do,  the  strict  boundary  between  epithelial  and  connective  tissue  cells. 
I  only  call  those  tumors  true  carcinomata  which  have  a  forma- 
tion similar  to  that  of  true  epithelial  glands  (not  the  lymphatic  glands), 
and  whose  cells  are  mostly  actual  derivatives  from  true  epithelium." 

If  the  cervix  uteri  has  been  first  affected,  the  disease  spreads  from  this 
point,  invades  the  whole  neck,  and  sometimes  the  body  of  the  uterus,  the 
ovaries,  vagina,  bladder,  and  intermediate  tissue.  Even  the  bones  of  the 
pelvis  may  be  attacked.  For  a  varying  length  of  time  the  deposition 
goes  on,  then  without  assignable  cause  the  lowly  organized  mass  begins  to 
die,  and  ulceration  or  molecular  death  occurs.  The  detritus  gives  rise  to 
a  fetid,  ichorous,  and  bloody  discharge,  which  excoriates  the  vulva  and 
thighs,  and  renders  the  patient  disagreeable  to  herself  and  all  around  her. 
The  disease  extends  to  neighboring  and  distant  organs  by  several 
methods :  first,  by  continuous  growth  ;  second,  by  absorption  of  conta- 
gious fluid  or  cell  elements  from  the  cancer  by  the  lymphatics  and  trans- 
mission to  the  glands  and  other  parts  ;  and  third,  by  venous  absorption. 

Varieties} — Cancer  may  attack  the  uterus  in  any  one  of  the  following 
forms  : — 

1st.  Scirrhus  ;  fibrous,  or  chronic  cancer  ; 

2d.  Encephaloid  ;  or  acute  cancer  ; 

3d.   Epithelioma  ;  cancroid,  or  epithelial  cancer. 
In  addition  to  the  varieties  of  cancer  thus  far  recorded,  a  fourth,  the 
colloid,  is  often  mentioned.     It  is  now  very  generally  regarded  as  incor- 

1  Although  to  he  systematic  I  have  deemed  it  best  to  adopt  these  conventional 
terms,  the  student  must  not  imagine  that  it  is  always  an  easy  matter  to  classify  a 
uterine  cancer  under  one  of  them.  Very  commonly  a  growth  will  be  met  with, 
which  occupies  a  middle  ground  between  these  varieties,  and  is  neither  pure  scir- 
rhus, encephaloid,  nor  yet  epithelioma. 


574  CANCER  OF  THE  UTERUS. 

rect  to  look  upon  this  as  a  true  variety  of  cancer,  for  it  is  rather  a  mucoid 
degeneration  of  one  of  the  preceding  varieties.  The  same  kind  of  de- 
generation may  affect  other  growths  ;  and,  if  the  mere  presence  of  colloid 
matter  were  used  as  the  test  of  malignancy,  many  errors  would  result. 
Virchow  declares  in  reference  to  this  important  point,  "  you  may,  there- 
fore, say  colloid  cancer,  colloid  sarcoma,  colloid  fihroma.  Here  colloid 
means  nothing  more  than  jelly-like."  When  this  change  has  affected  one 
of  the  other  varieties  of  cancer,  the  alveoli  are  found  very  large  and  filled 
with  jelly-like,  structureless  material. 

Cancerous  and  cancroid  affections  should  not,  with  the  light  which  we 
at  present  possess,  be  separated.  In  both  we  find  the  characteristics  of 
malignancy,  and  the  microscope  shows  the  same  type  of  cell  and  connec- 
tive tissue  structure.  It  is  certain  too,  that  the  physical  aspects  of  the 
varieties  of  cancer  depend  merely  upon  varying  proportions  and  anatomical 
arrangement  of  their  component  parts.  Before  proceeding  then  to  the 
details  of  this  subject  let  me  premise  this  fact,  that  all  the  affections  to  be 
here  treated  of,  whether  they  be  called  cancer,  cancroid,  or  epithelioma, 
are  really  malignant  in  character,  and  differ  as  to  malignancy  only  in 
degree;  and  that  in  all,  if  allowed  to  proceed  uninterfered  with,  systemic 
intoxication  is  only  a  question  of  time. 

Frequency. — Cancer  is  an  affection  of  frequent  occurrence,  and  is  more 
frequently  seen  in  the  uterus  than  in  any  other  organ.  According  to 
Rokitansky,1  the  following  average  scale  may  be  adopted  as  representing 
the  preference  of  cancer  for  various  organs.  "  First,  the  uterus,  the  female 
breast,  the  stomach,  the  large  intestines,  and  especially  the  rectum ;  next 
comes  cancer  of  the  lymphatic  glands,"  etc.  The  following  quotations 
will  fully  display  the  relative  frequency  of  cancer  of  the  uterus: — 

Of  all  cases  of  cancer  in  females,  the  uterus  is  affected  in  §,  Kiwisch.8 
"9118     "  "  "  "  was        "  2996,  Tanchou.8 

"  8746     "  "  "  "  "  "  3000,  Simpson.* 

"5122     "  "  "  "  "  "  113,  Wagner.8 

Statistics  prove  that  cancer  is  nearly  three  times  more  frequent  in  women 
than  in  men,  and  more  than  three  times  more  frequently  met  with  in  the 
uterus  than  in  any  other  organ  of  the  female. 

Relative  Frequency  of  the  Varieties Virchow6  regards  cancroid  affec- 
tions as  constituting  the  majority  of  so-called  uterine  cancers.  Hewitt7 
declares  that  "the  form  of  cancer  usually  witnessed  in  the  uterus  is  the 
medullary  cancer.     The  'epithelial'  comes  next  in  order  of  frequency." 

1  Sydenham  Trans.,  vol.  i.  p.  198,  Am.  ed.  8  Klob,  op.  cit.,  p.  205. 

8  Rech.  sur  les  Tumeur  du  Sein,  p.  218.  *  Clin.  Lect.,  p.  42. 

6  New  York  Med.  Journ.,  vol.  ix.  p.  561. 

6  Lusk's  rtsnmt,  N.  Y.  Med.  Journ.,  Sept.  1869,  p.  567. 

i  Op.  cit.,  p.  575. 


RELATIVE    FREQUENCY    OF    THE    VARIETIES.  575 

Courty1  begins  his  remarks  upon  this  subject  thus :  "  Epithelioma  of  the 
vaginal  portion  of  the  neck,  perhaps  the  most  frequent  of  uterine  can- 
cers,"  etc. 

So  rare  is  it  to  meet  with  the  scirrhous  form  of  uterine  cancer  that  some 
writers  have  doubted  its  existence.  Rokitansky  admits  the  possibility  of 
its  occurrence,  but  regards  it  as  extremely  uncommon.  The  reason  of 
this  is  the  fact  that  scirrhus  is  probably  the  earliest  form  assumed  by  the 
disease,  and  at  this  period  few  symptoms  showing  themselves,  no  exami- 
nation is  sought  by  either  physician  or  patient.  I  have  met  with  several 
undoubted  instances  of  it ;  to  the  history  of  one  of  which  I  shall  make 
allusion. 

Dr.  Treskatis  brought  to  my  clinique  at  the  College  of  Physicians  and 
Surgeons  a  woman  between  forty  and  fifty  years  of  age  who  had  been  for 
some  time  suffering  from  leucorrhcea  and  menorrhagia.  Upon  examina- 
tion by  touch,  I  found  the  cervix  very  large  and  exceedingly  hard  and 
resisting.  The  speculum  revealed  no  abrasion,  except  two  little  points 
about  the  size  of  pin-heads,  which  bled  freely  when  brushed  with  a  sponge. 
From  the  facts  that  the  patient  had  shown  no  previous  symptoms  of  uterine 
disease  which  could  have  resulted  in  areolar  hyperplasia,  that  there  was 
no  intrauterine  cause  for  menorrhagia  discoverable,  and  that  the  hardness 
of  the  neck  was  excessive,  I  ventured  upon  the  diagnosis  of  scirrhous 
cancer.  This  case  was  kept  under  observation  by  Dr.  Treskatis,  who 
subsequently  reported  that  it  had  fully  developed  itself  into  an  unquestion- 
able one  of  carcinoma,  as  evidenced  by  softening,  ulceration,  the  micro- 
scopic signs,  etc.  Klob2  maintains  that  the  disease  "in  the  majority  of 
cases  occurs  in  a  fibrous  medullary  form,  that  is,  in  the  rare  cases  in  which 
we  are  enabled  to  recognize  and  study  the  primary  condition  of  the  carci- 
nomatous growth  in  the  dead  body,  we  find  that  form  which  is  described 
under  the  name  of  fibrous  carcinoma  or  scirrhus,  whilst  in  those  cases  in 
which  the  disease  proves  fatal  we  generally  meet  with  the  distinct  medul- 
lary variety  of  carcinoma." 

After  the  first  or  hard  and  fibrous  stage  of  the  disease  has  lasted  for 
some  time,  prolific  generation  of  cells  occurs.  These  fill  the  alveolar 
spaces  in  the  framework  of  connective  tissue,  which  spaces  burst  and 
communicate  with  each  other,  and  the  whole  mass  grows  large  and  soft. 
After  still  greater  growth,  these  overcrowded  cell  spaces  open,  the  large 
vessels  supplying  them  give  forth  blood  freely,  and  ulceration  becomes 
established.  As  this  last  stage  advances,  the  bladder  is  affected  bv  an 
extension  of  the  morbid  matter  to  its  base.  Then  the  rectum,  the  lym- 
phatic vessels  and  glands  of  the  pelvis,  and  the  neurilemma  of  the  sacral 
nerves  may  become  invaded,  and  the  morbid  action  spread  to  all  the  tissues 
of  the  pelvic  cavity.     The  frequency  with  which  different  parts  are  secon- 

1  Traite  prat,  des  Mai.  de  l'Uterus,  etc.,  p.  875.  2  Op.  cit.,  p.  192. 


576 


CANCER    OF    THE    UTERUS. 


darily  affected  may  be  judged  of  by  the  following  facts  given  by  Dr. 
Arnott,1  of  the  Middlesex  Hospital : — 

In  34  cases  there  was  observed  no  secondary  deposit. 


20 
5 
3 
2 

1 
1 
1 


cancerous  affection  of  lymphatic  glands. 

"  "  the  ovaries. 

"  "  the  liver. 

"  "  the  lungs. 

"  "  the  heart. 

"  "  the  breasts. 

"  "  the  peritoneum. 


Scirrhous  cancer  presents  as  its  predominant  anatomical  characteristic 
the  large  amount  of  connective  tissue  and  the  small  amount  of  cellular 
elements  of  which  it  is  composed;  and  as  its  chief  clinical  feature,  its 
gradual  development  and  comparative  slowness  of  growth  and  progress. 
The  abundant  stroma  alluded  to  soon  contracts,  and  in  so  doing  checks 
epithelial  generation,  causes  atrophy  of  almost  all  but  peripheral  cells,  and 
by  compressing  bloodvessels  limits  vascular  supply.  These  growths  offer 
to  the  examiner,  before  ulceration  has  occurred,  a  hard,  nodular,  and 
resisting  surface. 

Fig.  230. 


Cancer  of  mamma  ;  stroma  and  cells.     (Billroth.) 

Encephaloid  cancer  of  the  cervix  is  characterized  by  a  small  amount  of 
stroma  and  a  large  amount  of  cells.     Clinically  it  is  marked  by  its  rapid 


'  Path.  Trans.,  1870. 


EPITHELIAL    CANCER. 


577 


growth,  tendency  to  hemorrhage,  and  early  disintegration.    Upon  physical 
examination  during  life  it  presents  a  soft,  lobulated,  elastic  surface. 

Figs.  230  and  231,  after  Billroth,  showing  the  arrangement  of  cellular 
and  connective  tissue  elements,  will  prove  instructive. 


Fig.  231. 


Connective  tissue  framework  of  cancer  of  mamma.     Brushed-out  alcohol  preparation. 

(Billroth.) 

Epithelial  cancer  differs  greatly  both  in  anatomical  and  clinical  features 
from  the  forms  just  enumerated,  and  claims  especial  consideration.  Com- 
mencing by  excessive  generation  of  the  cells  which  characterize  the  part 
upon  which  the  morbid  influence  is  excited,  it  develops  itself  always  in 
connection  with  epithelial  covered  surfaces — skin  or  mucous  membrane. 
In  some  cases  the  stroma  is  very  abundant;  in  others  it  is  almost  entirely 
wanting.  As  the  cells  increase  in  this,  they  arrange  themselves  into  epi- 
thelial brood  nests  or  spaces. 

The  importance  of  the  distinction  between  this  form  of  cancer  and  those 
previously  mentioned  is  at  present  not  as  generally  accepted  as  it  was 
twenty  years  ago.  At  that  time  pathologists  thought  it  necessary  to 
divide  cancers  into  two  separate  classes :  those  which  were  essentially 
true  cancer,  and  those  which  were  (eihoi)  like  unto,  though  not  identical 
with,  that  terrible  malady.  In  18-AG,  Lebert  gave  to  these  growths  the 
name  of  " cancroid"  for  the  reason  just  given;  and  in  1852,  Hannover, 
from  the  fact  that  this  variety  of  disease  was  known  to  consist  in  a  morbid 
hypergenesis  of  normal  epithelium,  called  them  "  epithelioma." 

For  a  long  time  the  current  of  opinion  appeared  to  set  in  favor  of 
making  a  wide  distinction  between  the  two  affections ;  one  being  looked 
37 


578 


CANCER    OF    THE    UTERUS, 


upon  as  a  disease  having  its  origin  in  a  peculiar  condition  of  the  system, 
and  the  other  as  one  of  local  nature  only.  More  recently  a  different  feel- 
ing has  prevailed,  pathologists  strongly  inclining  to  the  view  that  can- 
croid growths  are  really  members  of  the  family  of  cancers,  differing  from 
them  histologically  chiefly  in  the  features  which  I  have  mentioned.  On 
their  part,  clinicists  noticed  very  marked  differences,  chief  among  which 
are  tardiness  of  systemic  poisoning  in  cancroids,  and  slighter  tendency  to 
return  of  the  disease  after  amputation.  Rokitansky1  said  of  them  :  "  In 
many  cases,  however,  notwithstanding  precisely  the  same  morphological 
and  chemical  relations,  they  accord  so  entirely  in  all  their  manifestations 
with  the  cancers,  that  we  classify  them  with  these  as  a  further  variety  of 
medullary  carcinoma,  to  which  in  their  lineaments  also  they  approximate 

Fig.  232. 


WBfam 


''/wflwaSBk 

Flat  epithelial  cancer  of  cheek.    Glandular  ingrowth  of  rete  Malpighii  into  connective 
tissue.    (Billroth.) 

the  most  nearly.  This  occurrence  we  believe  to  be  limited  to  the  mucous 
membranes  and  the  common  integuments."  Virchow,  whose  investiga- 
tions have  been  later  than  those  of  Rokitansky,  regards  epithelioma  as 
well  as  cancer  as  due  to  a  generation  of  normal  cells  excited  into  a  morbid 
activity  by  the  unknown  influence  which  constitutes  the  cause  of  cancerous 
affections.  He2  has  demonstrated  the  development  of  cancroid  substance 
within  the  uterine  wall  as  well  as  upon  its  mucous  membrane. 

In  the  commencement  of  each  variety  of  malignant  disease  the  clinical 
differences  would  be  easily  recognized ;  but  as  epithelioma  advances,  and 
the  deeper  tissues  become,  involved,  a  differentiation  will  often  become  not 
only  difficult  but  impossible. 


'  Op.  tit.,  vol.  i.  p.  217. 


2  Klob,  op.  cit.,  p.  19. 


EPITHELIAL    CANCER.  579 

Epithelial  cancer  may  affect  the  uterus  in  two  entirely  different  forms. 

The  first  is  characterized  by  a  strong  tendency  to  ulceration  ;  the  second 

by  formation  of  a  tumor,  or  fungus-like  mass,  which  at  a  later  period  is 

attacked  by  ulceration.     These  forms  have  been  designated  as — 

Ulcerating  epithelioma ; 

Vegetating  epithelioma. 

The  term  corroding  ulcer  was  applied  by  Dr.  John  Clarke,  of  London, 
and  subsequently  by  his  brother  Sir  Charles  Mansfield  Clarke,  to  a  form 
of  ulcer  of  the  cervix  in  which  nothing  but  rapid  destruction  of  tissue  is 
noticed  as  a  pathological  lesion ;  in  which  there  is  no  hardness  of  the  part 
affected,  no  induration  nor  inflammation  of  surrounding  organs ;  nothing 
but  molecular  death  in  the  cervix  uteri,  and  disappearance  of  its  structure 
as  if  by  liquefaction.  It  has  been  described  under  the  names  of  rodent 
ulcer,  diffuse  ulcerative  cancer,  epithelial  cancer,  and  cancroid  of  the 
uterus. 

All  authorities  agree  that  this  affection  is  comparatively  rare.  Dr. 
Ashwell'  remarks  :  "  For  one  case  of  corroding  ulcer  we  meet  with  ninety 
or  a  hundred  of  cancer  of  the  uterus ;"  and  he  further  states  that  in  the 
appropriate  ward  at  Guy's  Hospital  at  the  time  of  his  writing,  not  one  ex- 
ample of  this  malady  had  appeared.  In  five  hundred  recorded  cases  of 
uterine  disease  in  that  hospital  not  one  case  of  corroding  ulcer  was  to  be 
found.  This  is  the  experience  of  all  authors  who  make  their  reports,  not 
from  clinical  but  from  careful  post-mortem  evidence.  Those  who  rely 
upon  clinical  observations  alone  report  the  disease  much  more  frequently ; 
but  it  is  highly  probable  that,  as  Scanzoni2  remarks,  an  error  has  been 
made  in  such  cases  with  reference  to  its  anatomical  characteristics.  It 
should  be  borne  in  mind  that  many  cases,  proved  by  the  microscope  in 
post-mortem  inspection  to  be  unquestionable  carcinoma,  have  run  a  course 
very  similar  to  that  of  this  affection.  Ashwell  states  that  on  several  occa- 
sions where  a  diagnosis  of  corroding  ulcer  had  been  made,  post-mortem 
examination  gave  evidence  of  other  forms  of  cancer  ;  and  Scanzoni  tells  of 
a  case,  occurring  in  the  clinique  at  Prague,  in  which  at  an  autopsy  all 
present  were  inclined  to  reverse  their  diagnosis  of  carcinoma  and  adopt 
that  of  corroding  ulcer,  until  the  matter  was  settled  by  necropsy. 

Pathologists  are  now  very  generally  agreed  that  this  affection  is  a  va- 
riety of  epithelial  cancer,  as  the  following  table  will  prove.  In  preparing 
it  no  author  is  quoted  who  wrote  over  thirty  years  ago. 

1  Dis.  of  Women,  p.  318.  2  Op.  cit.,  p.  217. 


580 


CANCER    OF    THE    UTERUS- 


Authority. 

Opinion  as  to  Pathology. 

Where  reported. 

Dr 

West.     .     .     . 

Epithelial  cancer  .... 

West  on  Diseases  of  Females, 
p.  270. 

Dr 

Graily  Hewitt  . 

A  form  of  cancer  .     .     .  •  . 

Hewitt  on  Diseases  of  Women, 
Amer.  ed.,  p.  211. 

Dr 

Churchill    .     . 

"  Essentially  different"  from 

Churchill  on  Diseases  of  Wo- 

cancer. 

men,  p.  208. 

M. 

Aran   .... 

Diffuse  ulcerating  cancer    . 

Aran,  Mai.  del'Uterns.p.  937. 

Dr 

Scanzoni 

Decomposed  medullary  can- 

Scanzoni  on    Diseases   of    Fe- 

cer. 

males,  p.  227. 

M. 

Nonat. 

Epithelial  cancer  .... 

Nonat,  Mai.  de  l'Uterus,  p.  521. 

M. 

Becquerel 

Epithelial  cancer  .... 

Becquerel,    Mai.   de   l'Uterus, 
torn.  ii.  p.  209. 

Dr 

Ashwell . 

Similar  to  lupus    .... 

Ashwell  on  Dis.  of  Females, 
p.  319. 

Dr 

H.  Bennet  .     . 

Epithelial  cancer  .... 

Bennet  on  Uterus,  p.  386. 

Mr 

De  Morgan  .     . 

"  A  modification  of  epithe- 

Essay before  Lond.  Path.  Soc, 

lioma." 

March,  1874.    . 

Mr 

Arnott    . 

"A  form  of  epithelioma."  . 

Discussion  before  London  Path. 
Soc,  March,  1874. 

Dr 

Byford    .     .     . 

Epithelial  cancer  .... 

Byford,  Med.  and  Surg.  Treat, 
of  Women. 

Dr 

Lever      .     . 

Malignant  ulcer    .... 

Lever  on  the  Diseases  of  the 
Uterus,  p.  149. 

Dr 

Kiwisch  . 

Decomposed  medullary  can- 

Scanzoni, Diseases  of  Females, 

cer. 

p.  227. 

M. 

Columbat  de 

Compares  it  to  noli  me  tan- 

On  Females. 

L'Isere 

gere. 

M. 

Courty      .     .     . 

Epithelial  cancer  .... 

Mai.  de  l'Uterus,  p.  875. 

Rokitansky1  alludes  to  the  disease  thus  :  "  We  also  find  primary  and 
syphilitic  ulcers,  cancerous  ulcers  that  have  resulted  from  the  fusion  of 
cancerous  morbid  growths,  the  so-called  phagedenic  ulcer  of  the  os  tinea?, 
Clarke's  corroding  ulcer.  The  latter  may  be  compared  to  the  phagedenic, 
cancerous  sore  of  the  skin  ;  without  having  a  morbid  growth  for  its  base  it 
gradually  destroys  the  cervix  and  even  the  greater  part  of  the  uterus,  and 
may  extend  to  the  rectum  and  bladder." 

"In  some  dissections  that  I  had  made,"  says  Mr.  Arnott,2  "it  seemed 
to  me  that  rodent  ulcer  was  a  form  of  epithelioma,  for  one  sees  deep  down 
an  appearance  like  the  cells  of  the  rete  mucosum,  and  occasionally  the 
bird's-nest  body;  the  cells  are  more  closely  coherent  than  in  epithelioma, 
because  they  resemble  more  the  cells  of  the  rete  mucosum,  not  the  epi- 
dermis cells ;  therefore  they  have  a  still  lower  malignancy  than  any  ordi- 
nary epithelioma." 

The  tendency  of  the  newly  formed  cells  is  to  rapid  death.  As  the  pro- 
cess of  destruction  advances   through   the   mucous    membrane    into    the 


'  Path.  Anat.,  Sydenham  ed.,  vol  ii.  p.  220. 
2  Discussion  before  London  Path.  Soc. 


EPITHELIAL    CANCER. 


581 


parenchyma  beneath  it,  and  profuse  hemorrhages  occur,  the  patient  is 
gradually  exhausted;  and  as  the  peritoneum  in  time  becomes  invaded, 
peritonitis  of  fatal  type  is  excited.  Unlike  other  cancers,  however,  its 
course  is  often  slow,  and  years  may  pass  before  death  results.  All  varieties 
of  cancer  ultimately  ulcerate.  The  prefix,  "  ulcerating,"  as  here  em- 
ployed, applies  only  to  that  variety  whose  primary  feature  is  to  break 
down  in  this  way. 

That  form  of  epithelioma  called  "  vegetating,"  and  which  has  been  at 
different  times  described  under  a  variety  of  names,  has  the  following  char- 
acteristic features :  it  consists  in  the  growth  of  a  lowly  organized  tumor, 
which  creates  hemorrhage,  fetid  discharge,  and  hydrorrhoea.  There  is  an 
extraordinary  development  of  cervical  villi,  an  increase  of  their  vessels, 
and  a  great  activity  in  the  growth  of  the  cells  which  cover  them  ;  a  "  pro- 
liferation," as  it  is  termed  by  Virchow.  A  morbid  influence,  the  nature 
of  which  is  unknown  to  us,  stimulates  the  activity  of  cell  growth,  so  that 
cells  thickly  cover  the  villi.  "  These  growths,"  says  Prof.  J.  H.  Bennet, 
"  speaking  generally,  are  almost  wholly  composed  of  epithelial  scales." 

Fig.  233. 


Transverse  section  of  a  vegetating  epithelioma.    (Virchow.) 

In  addition,  the  villi  increase  in  size  and  length,  their  bloodvessels  enlarge, 
and  a  true  papilloma  or  papillary  tumor  is  inaugurated.  "  The  gall-nut 
which  arises  in  consequence  of  the  puncture  of  an  insect,  the  tuberous 
swellings  which  mark  the  spots  on  a  tree  when  a  bough  has  been  cut 
off,  and  the  wall-like  elevation  which  forms  around  the  border  of  the 
wounded  surface,  produced  by  cutting  down  a  tree,  and  which  ultimately 


582  CANCER  OF  THE  UTERUS. 

covers  in  the  surface,  all  of  them  depend  upon  a  proliferation  of  cells  just 
as  abundant,  and  often  just  as  rapid  as  that  which  we  perceive  in  a  tumor 
of  a  proliferating  part  of  the  human  body."1  Fig.  233  represents  one  of 
these  growths  in  section. 

It  must  not  be  supposed  that  these  masses  are  supplied  with  blood  only 
by  the  vessels  of  the  villi.  These  ramify  outside  of  their  proper  canals, 
and,  running  into  the  masses  of  cells,  allow  of  transudation  of  serum, 
which  constitutes  the  watery  discharge  so  characteristic  of  the  disease, 
and,  being  ruptured,  give  forth  a  profuse  flow  of  blood. 

These  tumors,  commencing  as  papillary  hypertrophies  on  the  cervix  or 
os,  are  at  first  local,  but  in  time  affect  the  constitution.  They  are  some- 
times engrafted  upon  true  cancerous  deposit  in  the  cervical  parenchyma. 

Their  most  frequent  site  is  the  vaginal  portion  of  the  cervix,  but  from 
this  point  the  morbid  process  may  spread  into  the  uterine  cavity  or  down 
into  the  vagina.  An  important,  indeed  a  vital  question  as  to  such  growths 
is  this  :  is  every  cauliflower  excrescence  a  malignant  disease  ?  Virchow, 
than  whom  we  know  of  no  better  authority,  is  decidedly  of  opinion  that  it 
is  not.  "  The  pathological  importance  of  a  papillary  tumor,"  says  he,  "  is, 
at  least  as  far  as  I  know,  determined  by  the  condition  of  its  basis-substance, 
or  by  that  of  the  parenchyma  of  the  villi  themselves ;  and  a  formation 
can  only  be  pronounced  to  be  cancroid  or  carcinoma  when,  in  addition  to 
the  growth  of  the  surface,  the  peculiar  degenerations  which  characterize 
these  two  kinds  of  tumors  take  place  also  in  the  deeper  layers  or  in  the 
villi  themselves."  Virchow  then  believes  that  some  tumors,  resembling 
in  every  outward  aspect  vegetating  epithelioma,  are  really  non-malignant 
papillomata.  The  difference  between  these  and  the  real  epithelioma  is  to 
be  found  by  microscopic  examination  of  the  submucous  tissue.  In  the 
one  case  it  is  healthy,  in  the  other  diseased.  "  Whilst,"  says  Klob,  "  in 
the  benign  form,  simply  an  arborescent  framework  is  covered  by  a  more 
or  less  thick  layer  of  basement-epithelium,  in  the  cancroid  tumor,  so-called 
cancroid  alveoli  are  developed  in  the  substance  proper  of  the  tumor,  and 
also  in  the  '  parent  tissue,'  which  is  affected  with  hyperplasia  of  connec- 
tive tissue."  It  is  a  noteworthy  and  interesting  fact  that  this  opinion, 
arrived  at  by  these  learned  German  pathologists  by  careful  microscopic 
research,  was  maintained  as  a  result  of  clinical  observation  many  years 
ago  by  Gooch,  who  said :  "I  do  not  believe  that  any  man  can  tell  in- 
fallibly by  touch  whether  a  tumor  in  the  vagina  is  a  malignant  excrescence, 
which  is  to  grow  again,  or  a  benign  one,  which,  if  removed,  will  never 
return." 

The  pathological  condition  that  we  have  thus  far  described  may  be 
styled  the  first  stage  of  the  disease.  In  time  ulceration  occurs  in  the 
mass  thus  created,  which,  rapidly  breaking  down  its  tissue,  opens  large 

1  Virchow,  Cellular  Pathology. 


EPITHELIAL    CANCER.  583 

and  numerous  vessels,  and  destroys  life  by  long  continued  and  profuse 
hemorrhages. 

Klob1  describes  two  forms  of  malignant  papilloma ;  one  which  goes  on 
to  the  creation  of  a  tumor  of  some  size  and  then  breaks  down  ;  the  other, 
which  consists  merely  of  small  nodules  upon  the  cervix,  which  rapidly 
ulcerate  and  eat  away  this  part,  and  in  time  the  body  of  the  uterus. 
These  tumors  may  grow  from  the  vaginal  portion  of  the  cervix,  from  the 
cervical  canal,  or  from  the  mucous  membrane  of  the  body  of  the  uterus. 

The  authority  of  Virchow  has  been  already  quoted  to  prove  how  difficult 
is  a  differentiation  of  malignant  from  benign  papilloma.  Indeed,  Scanzoni 
declares  that  Virchow  is  of  opinion  that  "  the  excrescence  is  at  first  a 
simple  papillary  tumor,  which  afterwards  passes  into  a  cancroid  state." 
At  the  same  time  that  differentiation  is  difficult  in  such  a  case,  its  great 
importance,  as  affecting  the  validity  of  deductions  as  to  the  results  of 
treatment,  must  be  evident.  The  following  quotation  from  Graily  Hewitt's2 
excellent  work  will  illustrate  this  remark.     In  speaking  of  the  fatality 

Fig.  234. 


Vegetating  epithelioma.     (Simpson.) 

and  duration  of  cancerous  and  cancroid  affections,  he  says,  "  One  of  the 
most  valuable  facts  in  this  connection  is  given  by  Sir  J.  Y.  Simpson  in 
his  'Lectures  on  Diseases  of  Women.'  The  patient,  the  subject  of  the 
case,  had  a  large  cauliflower  excrescence,  the  size  of  an  egg,  removed 
eighteen  years  previously.  Since  that  period  she  has  had  five  children, 
and  was  still  alive.  With  reference  to  this  case  it  should  be  stated  that 
no  'caudate  or  spindle-shaped  bodies'  were  found  in  the  tumor  removed." 
Now  if  we  are  to  accept  the  revelations  upon  this  subject  made  by  recent 
investigators,  of  what  real  value  is  such  a  case?  It  is  more  likely  to 
mislead  than  to  guide  the  practitioner  correctly.  Klob,3  while  guarding 
against  the  fallacy  of  judging  by  external  appearances,  gives  this  method 
of  differentiation  by  the  microscope.      "In  simple  papilloma  there  is  a 

»  Op.  cit.,  p.  189.  2  Op.  cit.,  p.  578.  8  Op.  cit.,  p.  187. 


o84  CANCER  OP  THE  UTERUS. 

framework  covered  merely  by  a  thick  layer  of  basement-epithelium ;  in 
malignant  papilloma  there  are  alveoli  filled  with  cells  constituting  the  so- 
called  '  brood-cavities.' " 

Predisposing  Causes Those  predisposing  causes  which  are  generally 

admitted  may  be  thus  enumerated : — 

Hereditary  tendency ; 

Middle  or  advanced  life ; 

Race,  the  African  enjoying  partial  immunity ; 

Repeated  parturition ; 

General  depreciation  of  vital  forces. 
Hereditary  tendency,  once  generally  admitted  as  a  fruitful  predisposing 
cause,  is  now  questioned  by  many. 

Lebert  found  evidences  of  hereditary  tendency  in  14  out  of  102  cases. 
Paget  "  "  "  78       "     322     " 

Sibley  "  "  "  33       "     305     " 

More  recently  Sir  James  Paget  declares  that  in  his  experience  about 
one  case  in  three  has  been  hereditary. 

Although  cases  have  been  reported  at  the  extremes  of  womanhood,  it  is 
generally  admitted  that  few  occur  before  twenty  and  after  sixty.  The 
most  fruitful  period  is  from  40  to  50;  the  next  from  30  to  40;  the  next 
from  20  to  30;  and  the  next  from  50  to  60. 

Scanzoni  gives  the  ages  of  108  cases  treated  by  him. 


4  were  between  20  and  25. 
4     "  "         25  and  30. 

17  "    "    30  and  35. 

18  "    "    35  and  40. 


45  were  between  40  and  45. 
15  "    "    45  and  50. 

4  "    "    50  and  55. 

1  was    "    55  and  60. 


Tbe  youngest  was  23  and  the  oldest  59  years  of  age. 

The  black  races  appear  to  enjoy  to  a  limited  extent  immunity  from  this 
disease  when  compared  with  the  white. 

Prof.  Barker,  in  an  interesting  essay  upon  this  subject,  published  in  the 
Transactions  of  the  New  York  Academy  of  Medicine  for  1870,  cites  the 
following  statistics  by  Prof.  Chisholm,  of  Baltimore  : — 

Registrar's  report  in  South  Carolina  for  1859 — 

In  2423  deaths  among  whites,  20  were  ot  cancer ; 
In  7277     "  "       blacks,  29         "         " 

Judging  from  these  statistics,  the  exemption  of  the  black  races  is  by  no 
means  so  complete  as  the  general  impressions  of  many  practitioners  appear 
to  argue. 

Cancer  of  the  uterus  is  more  frequently  observed  among  multipara} 
than  nulliparae.     Of  Scanzoni's  108  cases— 


SYMPTOMS.  585 

8  had  been  delivered  11  times. 

3  "  "         10  " 

14  "  "  8  " 

13  "  "  7  " 

21  "  "  6  " 

10  "  "  5  " 

3  "  "4  " 

The  results  of  Mr.  Sibley's  investigations  in  the  Middlesex  Hospital  go 
to  prove  this  fact.  He  found  that  the  average  number  of  children  borne 
by  women  suffering  from  this  disease  was  30  per  cent,  in  advance  of  the 
average  number  of  all  marriages. 

Although  it  is  maintained  by  some,  that  cancer  as  commonly  affects 
persons  in  perfect  health  as  it  does  the  weak,  it  is  generally  admitted  that 
depreciating  influences  exerted  upon  the  general  system  have  a  predis- 
posing effect.  Among  these  may  be  especially  mentioned  grief  and  men- 
tal anxiety,  (observed  by  Scanzoni  84  times  in  108  cases,)  overlactation, 
the  existence  of  any  diathetic  state,  life  in  a  large  city,  and  the  state  of 
spanamiia  engendered  by  hard  labor,  exposure,  insufficient  food,  or  vicious 
habits. 

Exciting  Causes As  has  been  already  stated,  the  view  once  entertained 

by  many,  that  cancer  is  often  a  result  of  chronic  inflammation,  is  now 
generally  repudiated.  In  my  own  experience  I  have  yet  to  find  a  case 
even  remotely  sustaining  such  a  position.  There  is,  however,  believed  to 
exist,  to  use  the  words  of  Paget,  "  a  local  and  a  constitutional  origin  of 
cancer."  Mr.  Hutchinson  humorously  styles  cancer  "  a  rebellion  of 
cells."  It  is  the  cause  which  incites  this  rebellion  which  has  thus  far 
eluded  the  search  of  pathologists  and  clinicists  in  general  medicine  and 
surgery. 

"With  reference  to  uterine  cancer,  my  experience  certainly  goes  strongly 
to  sustain  the  opinions  of  Breisky,  Emmet,  and  others,  that  epithelioma 
of  the  cervix  very  generally  engrafts  itself  upon  a  laceration.  Laceration 
exposes  the  complicated  cervical  endometrium,  with  its  thousands  of  Na- 
bothian  follicles,  to  great  irritation,  which  in  time  produces  this  untoward 
result  in  a  certain  number  of  cases.  This  constitutes  of  itself  a  valid  rea- 
son for  a  resort  to  Emmet's  operation  in  cervical  laceration. 

Symptoms. — The  disease  may  pass  through  its  period  of  inception  and 
make  considerable  progress  towards  a  fatal  issue  without  developing  any 
symptoms  which  attract  the  attention  of  the  patient.  Or  only  slight  leu- 
corrhcea  and  hemorrhage  may  exist,  which  may  have  been  passed  over  as 
trivial  circumstances,  not  deserving  treatment  or  investigation.  Usually 
the  following  symptoms  develop  themselves  and  become  more  and  more 
prominent  as  molecular  death  advances  : — 

Pain  through  the  pelvis  ; 

Tenderness  upon  movement  or  coition  ; 

Menorrhagia  and  metrorrhagia ; 


586  CANCER  OF  THE  UTERUS. 

Ichorous  and  fetid  leucorrhoea  ; 

Hydrorrhea ; 

Dark,  grumous  discharge ; 

Constitutional  debility ; 

Pallor  and  cachectic  facies  ; 

Vesico-vaginal  or  recto-vaginal  fistula?. 
Pain  and  tenderness  are  not  nearly  so  constant  or  severe  as  is  often  sup- 
posed, and  they  may  both  be  entirely  absent. 

Menorrhagia  and  metrorrhagia  may  exist  even  before  ulceration  has  oc- 
curred, resulting  then  from  congestion  of  the  mucous  membrane.  But  it  is 
not  until  after  the  inauguration  of  the  process  of  destruction  that  they  be- 
come alarming  or  excessive. 

Ichorous,  watery,  and  grumous  discharges  very  generally  mark  the 
advance  of  the  disease.  The  first  of  these  discharges  produces  erythema, 
erosions,  vaginitis,  and  sometimes1  a  strong  sexual  appetite.  The  second 
exhausts  the  patient  by  draughts  made  upon  the  serum  of  the  blood.  The 
third  creates  fetor,  and  sometimes  results  in  septicaemia,  for  the  material 
giving  color  and  odor  to  the  flow  is  a  putrilage  formed  by  the  detritus  from 
the  decaying  uterus. 

Constitutional  debility  and  cachectic  facies  are  the  results,  in  part,  of 
the  malignant  toxaemia  which  is  the  basis  of  the  disorder,  in  part  of  ex- 
haustion produced  by  loss  of  blood  or  some  of  the  elements.  Should  the 
walls  of  the  rectum  and  bladder  become  implicated,  as  they  very  often  do, 
the  functions  of  these  viscera  are  deranged,  and  the  feces  or  urine,  or 
both,  pour  out  through  the  vagina,  increasing  the  misery  of  the  patient. 

Physical  Signs. — Suspicion  is  generally  first  aroused  and  physical  ex- 
ploration prompted  by  these  three  symptoms  :  menorrhagia,  fetid  discharge, 
and  ichorous  leucorrhoea.  They  belong  to  the  second  or  ulcerative  stage 
of  the  affection,  and,  as  Dr.  Henry  Bennet  has  well  established,  it  is  almost 
invariably  in  this  stage  that  the  physician  is  consulted.  Before  the  occur- 
rence of  this  stage  no  symptom  usually  exists  which  calls  for  physical 
exploration. 

As  I  have  already  stated  I  have  seen  but  two  cases  which  I  am  positive 
were  incipient  or  non-ulcerated  scirrhous  cancer.  In  these  the  diagnosis 
was  made  by  the  peculiarly  hard,  nodular  sensation  yielded  by  the  cervix, 
and  in  one  by  the  coincident  implication  of  the  vagina.  I  feel  sure, 
however,  that  he  who  ventures  upon  a  decision  as  to  the  nature  of  the 
disease  at  this  stage  must  expose  himself  to  great  risk  of  error.  The 
mere  fact  of  the  cervix  being  excessively  hard  and  nodular  is  not  enough 
to  warrant  a  diagnosis.  This  must  be  accompanied  by  other  reliable  signs, 
as  menorrhagia,  hydrorrhea,  and  constitutional  failure,  to  make  a  positive 
conclusion  admissible. 

1  I  have  never  met  with  this  symptom. 


DIFFERENTIATION.  587 

For  this  period  of  the  disease,  a  period  at  which  diagnosis  is  of  extreme 
importance,  in  view  of  the  fact  that  then  ahlation  offers  the  greatest  hope 
for  permanent  or  temporary  relief,  Spiegelherg  offers  a  valuable  resource 
in  the  use  of  sponge  tents.  If  the  induration  of  the  tissue  he  benign,  the 
dilating  influence  of  the  tent  will  produce  a  degree  of  softening,  while, 
if  it  be  due  to  malignant  disease,  the  tissue  will  remain  unyielding  and 
hard. 

After  ulceration  has  occurred,  diagnosis,  to  an  experienced  examiner, 
is  as  simple  and  certain  as  it  is  obscure  and  uncertain  before  it.  The 
finger  discovers  an  absolute  destruction  of  tissue,  and  finds  the  walls  of 
the  deep  and  ragged  ulcer  producing  it  covered  over  with  a  crumbling, 
brittle  mass,  interference  with  which  causes  hemorrhage.  The  uterus  is 
often  fixed  by  secondary  inflammation,  or  diffuse  deposit  of  cancerous 
matter,  and  the  walls  of  the  vagina  near  the  uterine  junction  participate 
in  the  deposit.  Sometimes  there  is  a  stricture  of  the  rectum,  which  espe- 
cially engages  the  attention  of  the  patient,  who  suspects  no  disease  of  the 
uterus  or  vagina. 

It  is  difficult  to  describe  to  another  the  peculiar  sensation  yielded  by  an 
ulcerating  cancer,  but  it  is  easy  to  appreciate  it  by  touch.  He  who  care- 
fully explores  one  case,  and  marks  the  hard,  unyielding  border  and  brittle 
surface,  with  its  marked  tendency  to  crumble  and  produce  hemorrhage, 
will  rarely  fail  to  recognize  another. 

Nevertheless,  it  is  in  all  cases  safe,  and  in  some  essential,  to  remove  a 
small  portion  of  the  cancerous  material  if  it  can  be  done  without  creating 
great  flow  of  blood,  for  examination  with  the  microscope.  And  now  arises 
the  question,  what  are  the  microscopic  tests  of  cancer?  This  subject  is 
one  which  I  cannot  leave  unnoticed,  and  yet  one  with  which  I  must  deal  as 
cursorily  as  is  consistent  with  a  concise  statement  of  the  existing  views 
of  pathologists  upon  it.  This  can,  I  think,  most  readily  be  done  by  a 
series  of  propositions. 

1st.  There  is  no  typical  cancer  cell,  which,  separated  from  its  surround- 
ings and  viewed  as  an  entity,  enables  a  microscopist  to  pronounce  upon  a 
growth. 

2d.  There  are  certain  combinations  of  cells,  alveoli,  and  stroma  which 
do  enable  a  microscopist  to  pronounce  an  opinion  as  to  the  benignity  or 
malignancy  of  a  growth. 

3d.  This  combination  consists,  in  general  terms,  in  the  existence  of  a 
fibrous  stroma,  containing  ovoid  alveolar  spaces,  filled  with  masses  of  cells 
with  large  single  or  multiple  nuclei,  and  all  bearing  more  or  less  closely  a 
resemblance  to  epithelium. 

Differentiation Upon   theoretical  grounds  it  might  be  supposed  that 

the  diagnosis  of  ulcerated  cancer  would  be  so  simple  that  few  errors  would 
occur  in  reference  to  it.  This  is  far  from  the  truth.  A  skilful  diagnos- 
tician would,  indeed,  generally  arrive  at  a  correct  conclusion,  but  I  know 


588  CANCER  OF  THE  UTERUS. 

of  no  disease  of  the  genital  organs  of  the  female,  unless  it  he  pelvic  peri- 
tonitis, which  so  frequently  gives  rise  to  errors  of  diagnosis  with  the 
inexperienced.     It  may  he  confounded  with — 

Eversion  of  cervix  from  laceration  ; 

Papillary  hypertrophy  of  the  cervix,  (cock's-comh  ulcer ;) 

Sloughing  fibrous  polypus ; 

Uterine  fibroids; 

Syphilitic  ulcer ; 

Areolar  hyperplasia  of  cervix  with  metrorrhagia ; 

Sarcoma  of  the  uterus  ; 

Retention  of  products  of  conception. 
From  these  a  differentiation  should  be  arrived  at  by  careful  study  of 
the  progress  of  the  case,  by  the  degree  of  constitutional  implication,  by 
the  results  of  microscopic  examination,  and  by  the  development  of  a  ten- 
dency to  return  after  removal.  A  positive  conclusion  is  not  always  easy, 
or,  without  delay,  even  practicable.  An  intelligent  decision  of  the  ques- 
tion must  depend  upon  care  in  investigation,  thoroughness  of  examination, 
and  upon  time,  which  in  most  cases  will  clear  up  all  doubt.  It  should  be 
remembered  that  the  diagnostician,  however  skilful  he  may  be,  who  bases 
an  opinion  upon  the  sensation  of  hardness  and  resistance  in  the  cervix,  is 
running  a  great  risk  of  error.  Let  it  be  borne  in  mind,  too,  that  syphi- 
litic ulcers  have  been  known  to  eat  into  the  bladder  and  rectum  and 
create  very  much  such  a  state  of  things  in  the  vagina  as  carcinoma 
develops. 

Prognosis The  prognosis  is  pre-eminently  unfavorable.     Not  only  is 

it  so  from  the  fact  that  the  disorder  is  cancerous,  but  because  that  form 
which  often  affects  the  uterus  belongs  to  the  most  rapid  and  dangerous  of 
its  varieties.  "Medullary  carcinoma,"  says  Rokitansky,  "is,  both  in  its 
development  and  in  its  subsequent  course,  the  most  acute  of  all  cancers." 
In  some  cases  death  will  ensue  in  from  three  to  six  months,  while  in 
others  it  may  not  occur  for  five,  six,  or  seven  years.  The  prognosis  should 
be  governed  in  great  degree  by  the  character  of  the  initial  affection  :  true 
carcinoma,  which  begins  with  profound  implication  of  subjacent  paren- 
chyma, runs  a  more  rapid  course  than  epithelioma,  which  often  involves 
only  superficial  portions  of  it.  The  general  experience  as  to  the  duration 
of  cancer  of  the  uterus  may  be  inferred  from  the  following  citation  of 
authorities: — 

Simpson  gives  as  an  average,  .         .         .         .     2  to  2£  years. 

Lebert  "  "  ....     about  16  months. 

West  "  "  ....     about  15  months. 

Barker  "  "  •         •         .         .3  years  and  8  months. 

The  termination  of  cancer  of  the  uterus,  if  the  disease  be  uninterfered 
with,  is  very  generally  a  fatal  one,  although  it  is  admitted  that  there  is  a 


COMPLICATIONS.  589 

possibility  that  the  mass  may  slough  away,  the  surface  heal  over,  and  the 
patient  recover.  Scanzoni,  Kokitansky,  Kiwisch,  Virchow,  and  Klob,  all 
announce  this  fact,  strange  though  it  may  appear  to  one  who  has  always 
taken  a  more  gloomy  view.  "The  cases  of  spontaneous  recovery  from 
uterine  cancer,"  says  Kokitansky,1  "are  of  extreme  rarity,  but  they  do 
occur."  "In  opposition  to  the  above  phenomena,  which  inevitably  lead 
to  death,"  says  Klob,2  "the  universally  acknowledged  possibility  of  spon- 
taneous recovery  from  uterine  cancer  is  interesting."  Let  it  be  remem- 
bered that  these  authors  distinguish  between  cancer  and  cancroid,  and  are 
here  writing  of  the  former. 

Under  these  circumstances  the  whole  vaginal  portion  of  the  cervix  usu- 
ally sloughs  oh",  and  the  os  internum  becomes  the  os  externum.  Instances 
of  spontaneous  recovery  from  true  carcinoma  are  so  rare  and  interesting 
that  I  refer  the  reader  to  the  history  of  a  case  recorded  by  Prof.  Habit,  of 
Vienna,  which  will  be  found  in  the  Syd.  Soc.  Year-Book  for  18G4,  at 
page  401. 

When  death,  which  is  the  almost  inevitable  issue  of  cancer,  does  occur, 
it  is  usually  due  to  hemorrhage,  irritative  fever  which  assumes  a  typhoid 
form,  septicaemia,  uraemia,  anaemia,  or  some  one  or  more  of  the  numerous 
complications  which  I  now  come  to  enumerate. 

Complications The  following  are  the  complications  which  most  fre- 
quently accompany  the  disease  : — 

Septicaemia  from  absorption  of  putrid  fluid  ; 

Cellulitis ; 

Hydronephrosis  ; 

Peritonitis  ; 

Tetanus ; 

Phlebitis  ; 

Embolism  ; 

Cancer  in  lymphatic  glands  or  other  organs. 
In  rare  cases,  as  has  been  pointed  out  by  Beatty,  Cruveilhier,  and 
others,  cancerous  degeneration  obstructs  the  ureters,  and  produces-  in  this 
way  uraemic  poisoning.  Dr.  Theophilus  Parvin  records  an  instance  of 
this  character  in  which  for  a  week  no  urine  found  its  way  into  the  blad- 
der, and  the  symptoms  of  uraemia  were  well  marked. 

Part  of  Uterus  Affected — Cancer  much  more  frequently  affects  the 
neck  than  the  body  of  the  uterus,  although  some  authors,  with  whom  I 
decidedly  agree,  look  upon  cancer  of  the  body  as  much  more  common  than 
is  generally  thought. 

Although  cancer  developed  in  the  body  of  the  uterus  has  attracted  very 
little  attention,  it  is  by  no  means  exceedingly  rare.  Dr.  West  has  met 
with  it  in  two  out  of  one  hundred  and  twenty  cases  of  malignant  uterine 

1  Op.  cit.,  vol.  ii.  p.  228.  2  Op.  cit.,  p.  203. 


590  CANCER  OF  THE  UTERUS. 

disease,  and  Sir  James  Simpson  looks  upon  its  frequency  as  represented 
by  two  out  of  every  thirty  cases. 

The  most  marked  feature  of  the  affection  thus  making  its  appearance  is 
the  obscurity  which  attends  diagnosis.  For  a  long  time,  and  perhaps 
throughout  the  case,  uterine  hemorrhage  and  fetid  discharges  will  be  the 
only  symptoms  which  will  excite  suspicion.  These  leading  to  further  and 
fuller  exploration,  a  portion  of  the  morbid  tissue  will  be  removed  by  the 
curette,  examined  by  the  microscope,  and  thus  the  diagnosis  will  be  es- 
tablished. 

Scirrhus,  which  is  so  rare  as  to  be  denied  by  some  even  in  the  neck, 
never  affects  the  body,  and  so  rarely  does  encephaloid  do  so  that  some 
pathologists  declare  that  no  unquestionable  case  is  on  record.  The  sup- 
posed cases  are,  according  to  them,  really  instances  of  sarcoma,  tubercu- 
losis, or  sloughing  fibroid  growths.  When  malignant  disease  does  originate 
in  the  cavity,  it  assumes  the  form  of  epithelioma. 

Peculiar  Features  of  Cancer  of  the  Body The  symptoms  which  mark 

the  condition  are  : — 

Hemorrhage,  especially  if  occurring  after  the  menopause; 
Depreciation  of  vital  forces  ; 
Cachectic  appearance  ; 
Fetid  discharge ; 

Pains  of  severe  and  lancinating  character. 
These  symptoms  having  led  to  examination  of  the  uterus,  the  following 
physical  signs  will  probably  be  recognized  : — 

Enlargement  and  hardening  of  uterine  body  noticed  by  bi-manual 

palpation  ; 
Increased  capacity  of  uterus  ascertained  by  the  probe  ; 
Profuse  hemorrhage  upon  probing; 
Uterine1  tenesmus  with  dilatation  of  os ; 
Recognition  of  peculiar   intra-uterine  growth    by  introduction   of 

finger ; 
Microscopic  evidences  of  cancer. 
Differentiation  of  Cancer  of  the  Body — "When  the  rational  and  phys- 
ical signs  here  enumerated  are  carefully  developed  and  considered,  a  very 
probable  diagnosis  may  be  arrived  at.     Nevertheless,  errors  of  diagnosis 
are  common  in  reference  to  this  disease  at  the  hands  of  practitioners  who 
are  not  familiar  with  the  subject,  or  who  rely  too  firmly  upon  one  or  two 
of  these  signs  or  symptoms.     I  have  seen  each  one  of  the  following  con- 
ditions mistaken  for  cancer  of  the  body,  and  some  of  them  I  have  known 
to  have  repeatedly  caused  erroneous  diagnosis  : — 
A  sloughing  fibroid  ; 
A  retained  placenta ; 

1  Courty,  op.  cit.,  p.  580. 


TREATMENT.  591 

A  sponge  left  by  accident  in  utero ; 
Syphilitic  disease  of  pelvic  bones  ; 
Periuterine  cellulitis  or  peritonitis  ; 
Cystic  degeneration  of  chorion  (hydatids)  ; 
Fibroid  tumors  or  polypi  ; 
Entero-uterine  fistula ; 
Intra-uterine  vegetations. 
I  do  not  deem  it  necessary  to  go  into  detail  upon  the  means  necessary 
for  accomplishing  the   differentiation  of  these  affections  from   malignant 
disease.     It  will  suffice  to  say  that  in  cases  in  which  doubt  exists  after 
careful   investigation  by  all  the  other  means  here  recommended,  removal 
of  a  small  portion  of  a  mass  and  its  examination  by  the  microscope  will 
prove  of  the  greatest  assistance,  and  will  probably  decide  the  question.1 

The  removal  of  a  portion  of  intrauterine  cancerous  growth  may  be  ac- 
complished in  three  ways.  The  simplest,  and  consequently  the  best,  is  to 
introduce  a  silver  catheter,  turn  it  around  once  or  twice,  and  then  with- 
draw it.  Upon  blowing  through  the  manual  extremity  a  piece  of  the 
growth  large  enough  for  examination  will  generally  be  obtained,  for  these 
masses  are  usually  very  friable.  Should  none  of  the  growth  be  obtained 
in  this  way,  a  curette  may  be  passed  gently  into  the  uterus,  and  greater 
force  applied  for  the  detachment  of  a  portion.  Should  even  this  fail  the 
os  should  be  dilated  by  tents,  and  the  desired  specimen  obtained  either  by 
the  finger,  a  wire-loop  curette,  or  Emmet's  forceps. 

Treatment — The  indications  for  treatment  are  these  : — 
To  amputate  or  destroy  the  diseased  part  as  completely  as  possible ; 
To  check  hemorrhage  ; 
To  relieve  pain ; 

To  secure  perfect  cleanliness  and  correction  of  fetor ; 
To  sustain  the  general  strength. 
Review  the  complications  of  uterine  cancer,  and  it  will  be  seen  that 
many  of  them  are  of  a  most  fatal  character,  and  at  the  same  time  entirely 
beyond  the  resources  of  art.  A  certain  number,  however,  which  would 
prove  fatal  if  not  avoided  or  checked,  are  temporarily  under  the  control 
of  the  physician.  Examples  of  these  are  septicaemia,  hemorrhage,  ex- 
haustion from  pain,  ichorous  leucorrhoea,  hydrorrhoea,  excessive  constitu- 
tional debility  from  the  depraved  blood-state,  and  last,  though  not  least, 
the  extreme  mental  depression  which  is  the  consequence  of  bereaving 
the  unfortunate  sufferer  of  all  hope. 

No  single  plan  fulfils  so  many  of  the  indications  for  alleviating  these  as 

1  It  may  be  of  service  to  practitioners  at  a  distance  from  cities  in  which  compe- 
tent microscopists  reside,  to  state  that,  in  sending  specimens  for  examination,  the 
best  preservative  menstruum  consists  of  glycerine  diluted  with  water.  Alcohol, 
carbolic  acid,  and  similar  fluids  contract  and  harden  the  structures  to  such  an 
extent  as  to  render  them  unfit  for  examination. 


592  CANCER  OP  THE  UTERUS. 

removal  or  destruction  of  the  growth,  but  no  practice  in  reference  to  this 
disease  can  be  so  pernicious  as  that  based  upon  the  idea  that  because  there 
is  cancer  of  the  uterus  some  surgical  procedure  must  be  resorted  to.  The 
same  reasoning  which  applies  to  malignant  diseases  in  other  parts  of  the 
body  should  do  so  here.  If  the  operator  be  convinced  that  decided  bene- 
fit is  to  accrue  to  the  patient  from  surgical  interference,  it  should  be  prac- 
tised; not  otherwise.  Should  the  disease  be  detected  early,  and  sufficient 
grounds  be  discovered  for  a  positive  diagnosis,  the  propriety  of  complete 
removal  of  the  cervix  by  amputation  cannot  be  questioned.  If  the  dis- 
ease be  scirrhous  or  encephaloid  cancer,  and  not  epithelioma,  the  operative 
procedure  will  generally  fail  in  effecting  a  cure,  but  will  probably  not 
hasten  a  fatal  issue.  If  it  be  the  latter,  a  cure  may  possibly  be  accom- 
plished. 

In  the  great  majority  of  cases,  patients  suffering  from  uterine  cancer 
are  seen  so  late  that  surgical  interference,  established  with  a  view  to  cure, 
necessarily  fails  to  effect  it ;  although,  practised  for  relief  of  certain  symp- 
toms, and  thus  for  a  prolongation  of  life,  it  is  frequently  of  a  great  deal 
of  benefit.  Should  amputation  of  the  neck  promise  entire  removal  of  the 
morbid  tissue,  it  should  at  once  be  accomplished,  for  by  it  cure  may  be 
effected.  Even  where  complete  removal  is  not  practicable,  ablation  of  all 
the  superficial  portions  of  the  growth  tends  greatly  to  the  amelioration  of 
symptoms. 

There  are  several  surgical  procedures  by  which  removal  of  the  diseased 
structure  may  be  effected.  One  of  these  will  be  most  applicable  to  one 
case,  one  to  another ;  that  being  always  selected  which  in  the  particular 
case  will  accomplish  the  end  with  the  greatest  thoroughness.  Let  it  always 
be  borne  in  mind  that  the  hope  of  prolonged  freedom  from  relapse  depends 
upon  thoroughness  of  ablation  and  upon  that  alone. 

I  will  describe  three  operations  for  removal  of  the  cancerous  cervix 
uteri. 

1st.  Simple  amputation  by  the  galvano-caustic  wire. 

2d.  Amputation  by  the  galvano-caustic  wire  followed  by  the  use  of 
Simon's  scoop,  the  knife  or  the  scissors. 

3d.  Removal  of  the  diseased  texture  by  Simon's  scoop,  and  of  all  the 
hard  subjacent  structures  which  can  with  safety  be  removed  by  the  knife 
or  scissors,  followed  by  searing  the  exposed  surface  thoroughly  with  Paque- 
lin's  thermo-cautery. 

In  the  selection  of  the  appropriate  operation  for  malignant  disease  of 
the  cervix  uteri,  the  operator  should,  as  far  as  possible,  ascertain  the  extent 
to  which  the  tissues  above  the  cervico-vaginal  junction  are  involved.  To 
ascertain  this  the  cervical  canal  should  be  dilated  by  tents  so  that  the 
finger  can  pass  freely  up,  and  a  careful  rectal  examination  should  also 
be  made.  The  information  thus  obtained  is  not  entirely  reliable,  but  is, 
nevertheless,  of  great  value.     Having  obtained  the  desired  information  in 


TREATMENT.  593 

this  way,  the  special  operation  to  be  resorted  to  should  be  selected  upon 
the  following  grounds. 

If  the  disease  be  found  to  limit  itself  to  the  cervix  below  a  line  which 
would  represent  the  course  which  would  be  followed  by  the  galvano-caustic 
wire,  amputation  by  that  instrument  would  be  the  most  appropriate  ope- 
ration. 

If  the  endometrium  be  found  to  be  diseased  above  this  point,  the  pre- 
sumption being,  of  course,  that  the  morbid  action  involves,  to  a  greater  or 
less  degree,  the  subjacent  parenchyma  likewise,  while  the  circumferential 
tissues  of  the  cervix  admit  of  a  safe  resting  place  for  the  galvano-caustic 
wire,  amputation  by  it  might  be  adopted,  followed  by  removal  of  a  cone 
of  diseased  tissue  by  Simon's  scoop  or  Sims's  knife  ;  or  the  operation  next 
to  be  mentioned  might  be  preferred. 

Should  the  circumference  of  the  cervix  be  involved  up  to  the  vaginal 
junction,  the  softened,  friable  tissue  gives  so  poor  a  basis  for  fixation  of 
the  wire,  that  galvano-cautery  proves  under  these  circumstances  a  most 
unsatisfactory  procedure,  and  should  be  replaced  by  the  scoop,  the  scissors, 
the  knife,  or  a  combination  of  the  three  instruments. 

One  of  the  great  objections  to  the  use  of  the  galvano-caustic  wire  for 
amputation  of  the  cervix  uteri  is,  that  it  deludes  the  operator  into  the 
belief  that  the  whole  cervix  is  being  removed  while  in  reality  the  wire 
slips  down  and  a  mere  scalping  process  is  gone  through  with.  This  I  have 
succeeded  in  entirely  preventing  by  the  instrument  shown  in  Fig.  23a. 

Fig.  235. 


Forceps  for  amputating  the  cervix. 

By  the  screw,  which  slides  up  and  down,  the  cervix  is  pulled  down 
into  the  bite  of  the  forceps,  which  is  then  closed  and  clamped  and  the 
screw  is  reversed  and  lowered.  The  wire  loop  is  then  passed  over  the 
most  prominent  part  of  the  diamond-shaped  sides  of  the  forceps,  and, 
being  tightened,  slides  to  its  highest  point. 

This  part  of  the  procedure  is  best  performed  with  the  patient  anaesthe- 
tized and  lying  in  Sims's  position,  and  his  largest  sized  speculum  in 
38 


594 


CANCER    OF    THE    UTERUS. 


place.  If  this  be  found  very  difficult  of  performance,  the  operator  may, 
by  vulsella,  pull  the  uterus  down  to  the  vulva. 

The  best  and  simplest  batteries  for  this  purpose  are  those  of  Byrne,  of 
Brooklyn,  and  Dawson,  of  New  York.  Both  of  them  are  very  small, 
compact,  and  reliable. 

If,  after  the  incandescent  wire  has  cut  through  the  circumferential 
tissues  of  the  cervix,  traction  be  made,  the  gradually  weakening  structure 
will  yield,  and  the  result  will  be  a  conical  amputation,  as  Dr.  Byrne  has 
pointed  out,  somewhat  resembling  the  diagram  exhibited  in  Fig.  236, 
though  of  course  the  cone  removed  will  be  much  less  extensive. 

Fia.  236. 


Cervix  amputated  and  parts  above  cut  out. 


It  has  been  said  that  the  cold  knife  is  better  in  the  performance  of  this 
operation  than  the  incandescent  one,  because  the  former  allows  the  opera- 
tor to  test  by  his  fingers  the  existence  of  diseased  tissue,  and  then  guide 
him  as  to  the  propriety  of  its  removal.  This  is  a  specious  argument,  for 
as  much  tissue  should  be  removed  in  every  case  as  the  operator  thinks 
compatible  with  safety. 

I  have  operated  in  this  way  on  many  occasions,  and  I  cannot  imagine 
any  more  complete  method  for  accomplishing  the  end  in  view  in  the  class 
of  cases  which  I  have  cited. 

After  every  such  operation  the  vagina  should  be  securely  tamponed 
with  styptic  carbolized  or  thymolized  cotton  for  at  least  ten  days,  a  tam- 
pon being  introduced  once  in  twenty-four  or  thirty-six  hours.  This  is 
troublesome,  but  I  have  seen  the  most  dangerous  hemorrhage  occur  under 


TREATMENT.  595 

these  circumstances  on  the  ninth  day  after  operation.  Indeed  it  must  be 
borne  in  mind  by  every  operator  that  reliance  upon  the  hemostatic  powers 
of  electro-cautery  in  this  operation  is  a  delusion,  and  a  most  hazardous  one. 

Should  it  be  found  that  sufficient  tissue  has  not  been  removed  by  this 
procedure,  the  second  should  be  added  to  it.  The  central  portion  of  the 
stump  being  seized  by  a  tenaculum,  its  core  should  be  removed,  to  as 
great  an  extent  as  the  operator  deems  safe,  by  Simon's  scoop,  the  long- 
handled  scissors,  or  Sims's  knife,  so  as  to  make  the  uterus  resemble  the 
schematic  diagram  shown  in  Fig.  236. 

But  cases  not  rarely  show  themselves  in  which  the  soft,  friable,  malig- 
nant material  offers  no  rest  for  the  wire  of  the  galvano-caustic  battery, 
and  in  which  it  is  difficult  to  draw  down  the  cervix  by  a  tenaculum. 
Here  all  the  softer  cancerous  masses  should  be  scooped  out  after  Simon's 
method  by  his  scoop  shown  in  Fig.  237.     The  hemorrhage  which  occurs 

Fig.  237. 


G.TIEMAWl  &  CD 

Simon's  scoop. 

is  often  alarming.  Its  control  depends  upon  two  things,  rapidity  and 
boldness  on  the  part  of  the  operator.  So  soon  as  all  the  cancerous  mate- 
rial is  removed,  the  flow  of  blood  will  cease,  or  rather  greatly  diminish. 
Let  such  removal  then  be  accomplished  as  rapidly  as  possible. 

After  removal  of  all  the  soft  tissue  which  the  scoop  can  remove,  the 
cervix  should  be  cut  away  by  scissors  or  knife  up  to  the  vaginal  junction, 
and  all  hard  tissues  above  which  are  susceptible  of  safe  removal  should  in 
the  same  manner  be  taken  away.  Then  the  cavity  of  the  body  should  be 
thoroughly  scraped  with  Sims's  cutting  curette. 

All  hemorrhage  should  then  be  controlled,  and  all  exposed  tissues  seared, 
by  means  of  Paquelin's  thermo-cautery  at  a  red  heat. 

The  heat  reflected  from  the  thermo-cautery  is  often  very  objectionable. 
To  protect  against  this,  Dr.  Wilson,  of  Baltimore,  has  invented  an  inge- 
nious little  shield  which  obviates  the  difficulty  entirely. 

It  will  be  seen  that  all  these  means  lead  up  to  one  issue.  That  will 
always  be  best  which  is  most  thorough,  and,  as  all  offer  the  opportunity 
for  great  thoroughness,  it  follows  that  success  in  their  application  will 
depend  much  more  upon  the  hand  which  applies  the  method,  than  upon 
the  method  itself. 

All  the  cancerous  material  which  can  be  removed  having  been  taken 
away  by  any  of  the  plans  mentioned,  the  surgeon  should  not  regard  his 
task  as  yet  finished.  The  bleeding  stump  should  be  thoroughly  cauterized 
by  the  actual  cautery,  nitric,  or  chromic  acid.  But  just  after  the  opera- 
tion, blood  oozes  too  freely  for  either  of  the  two  fluid  acids  mentioned  to 


596  CANCER  OF  THE  UTERUS. 

be  used.  It  has,  therefore,  been  advised  to  tampon  the  excavated  cervix 
by  means  of  cotton  saturated  with  strong  solutions  of  zinc,  bromine,  etc. 
The  unmanageable  character  of  such  tampons,  however,  as  to  the  degree 
of  sloughing  which  they  produce,  renders  them  highly  objectionable,  and 
the  scientific  surgeon  feels  too  surely  that  he  is  imitating  the  erratic  prac- 
tices of  the  "cancer  curer."  Paquelin's  thermo-cautery,  brought  to  a 
red  heat,  may  be  used  to  cheek  hemorrhage  and  to  destroy  the  base  upon 
which  the  cancer  grew.  Should  it  stop  the  hemorrhage  entirely,  it  may 
be  followed  by  one  of  the  acids  mentioned ;  if  not,  by  a  tampon,  which  being 
removed  in  twenty-four  hours,  cauterization  by  the  acid  may  be  practised. 

After  all  these  operations  I  would  recommend  putting  two  or  three 
silver  wire  stitches  on  each  side,  so  as  to  make  the  two  halves  of  the 
stump  face  each  other.  They  will  probably  not  unite  by  first  intention. 
That  is  not  the  object  of  the  procedure.  The  granulating  stump  will  be 
protected  from  friction  by  partial  union,  and  will  progress  much  better 
than  it  will  do  if  left  entirely  exposed.  After  doing  this,  and  at  the  end 
of  twelve  or  fourteen  days  removing  the  sutures,  I  have  been  surprised  to 
see  how  perfect  the  mutilated  parts  appeared.  This  is  only  an  imitation 
of  Sims's  procedure  for  covering  the  stump  and  securing  union  by  first 
intention  after  his  amputation. 

Although  cancer  of  the  uterus  is  in  itself  no  more  malignant  in  type 
than  that  of  other  parts,  the  mamma,  for  instance,  it  is  much  more  difficult 
of  entire  removal,  for  the  reason  that  its  existence  is  generally  ascertained 
later  in  the  progress  of  the  case,  and  thus  it  has  involved  deeper  layers  of 
parenchyma  and  has  encroached  more  upon  neighboring  organs. 

"Where  it  is  decided  not  to  resort  to  surgical  resource,  great  advantage 
often  accrues  from  destruction  of  the  superficial  layer  of  diseased  tissue  by 
chemically  pure  nitric  acid.  To  apply  this  the  cervix  should  be  exposed 
by  Sims's  speculum,  cleansed  by  a  stream  of  water  from  a  syringe,  and 
thoroughly  dried  by  dossils  of  cotton  or  sponge.  Then  the  acid  should, 
by  means  of  cotton  wrapped  around  a  rod,  be  thoroughly  applied  to  the 
whole  diseased  surface.  After  this  a  stream  of  water  should  be  again 
projected  upon  the  cervix,  and  a  pad  of  cotton  saturated  with  glycerine 
made  to  envelop  it.  The  caustic  application  produces  a  decided  slough, 
which  destroys  many  of  the  bloodvessels  which  have  proved  the  source  of 
hemorrhage.  I  regard  this  as  one  of  the  best  methods  for  accomplishing 
partial  destruction  of  a  cervix  affected  by  cancer,  and  resort  to  it  fre- 
quently in  practice  with  excellent  results.  Such  an  application  may  be 
repeated  once  in  two  or  three  months ;  and  it  is  curious  to  see  how 
patients  will  urge  a  repetition  of  it.  I  can  fully  indorse  the  statement  of 
Dr.  Churchill,  who  thus  speaks  of  the  use  of  strong  nitric  acid  as  a  caustic: 
"I  have  found  it  relieve  pain,  arrest  hemorrhage,  and  restrain  the  dis- 
charges. In  one  case,  hopeless  when  I  first  saw  her,  life  was  prolonged 
for  three  years  under  this  treatment." 


TREATMENT.  597 

If  chemically  pure  acid  be  obtained  and  efficiently  applied,  it  will  fulfil 
every  indication  required  of  an  escharotic.  I  have  discarded  in  its  favor 
all  the  more  violent  ones,  such  as  potassa  fusa,  the  actual  cautery,  etc. 

The  injection  of  escharotics  into  cancerous  growths,  by  means  of  the 
hypodermic  syringe,  has  of  late  years  been  practised,  and  gained  some 
favor.  But,  with  the  caustics  which  we  possess,  complete  destruction  of 
any  malignant  growth  upon  the  cervix  or  in  the  body  of  the  uterus  is  so 
easy  and  simple  a  matter  that  it  is  difficult  to  conceive  why  a  resort  to 
"parenchymatous  injections"  should  ever  become  necessary. 

Means  which  destroy  the  superficies  of  the  cancerous  mass  have  a  de- 
cided influence  in  controlling  hemorrhage.  It  may  further  be  controlled 
by  rest  during  menstruation  and  by  astringent  vaginal  injections.  The 
most  appropriate  styptics  are  the  sulphates  of  alum,  zinc,  and  copper,  alone 
or  combined,  in  about  the  strength  of  one  or  two  drachms  to  the  pint  of 
water. 

The  relief  of  pain  should  be  accomplished  by  the  free,  unrestricted  use 
of  opium  by  the  mouth,  the  rectum,  or  under  the  skin.  I  often  encourage 
my  patients  to  become  opium  eaters,  and  urge  them  to  obtain  as  complete 
relief  as  the  use  of  this  drug  can  afford.  In  place  of  opium,  other  narcotics 
may  be  tried,  but  there  is  none  which  compares  with  it  for  efficiency.  In 
some  cases  the  hydrate  of  chloral  in  scruple  doses  will  be  found  to  answer 
an  excellent  purpose,  either  as  an  alternate  or  a  substitute  for  opium.  It 
produces  sleep,  quiets  pain,  and  is  free  from  those  consequences  which 
frequently  render  opium  objectionable. 

When  opium  produces  the  painful  results  noticed  where  an  idiosyncrasy 
exists  against  it,  the  persistent  use  of  it  will  often  effect  a  tolerance.  In 
these  cases  the  hypodermic  use  of  morphia  often  becomes  the  greatest  boon. 

It  is  wonderful  to  see  what  large  amounts  of  opium  may  be  consumed, 
not  only  without  danger,  but  with  absolute  benefit,  for  relief  of  the  pains 
of  cancer.  Pinel  is  said  to  have  administered  to  a  woman  at  La  Charite 
120  grains  of  solid  opium  in  twenty-four  hours  ;  Marc  allowed  a  patient 
to  take  G2  grains  of  morphine  in  the  same  time  ;  and  Monges  and  La 
Roche,  of  Philadelphia,  gave  three  pints  of  laudanum  in  twenty-four  hours, 
and  kept  up  its  administration  at  this  rate  for  three  months.  Dr.  Knight, 
of  New  Haven,  had  a  patient  who  consumed  three  drachms  of  morphine 
in  twenty-four  hours,  and  continued  the  use  of  this  drug  for  a  considerable 
time  in  amounts  almost  equal  to  this.1 

The  fetor  of  the  discharges  may  be,  to  a  great  extent,  corrected  by  the 
use  of  vaginal  injections  containing  disinfectant  substances  in  solution.  A 
solution  of  carbolic  acid  or  thymol,  Labarraque's  solution  of  soda,  powdered 
persulphate  of  iron  or  sulphate  of  copper,  or  a  weak  solution  of  the  iodide 

1  These  facts  are  recorded  in  Dr.  Calkin's  valuable  work  on  "Opium  and  the 
Opium  Habit."     Lippincott  &  Co.,  Philadelphia. 


598  CANCER  OF  THE  UTERUS. 

of  lead,  will  prove  very  useful.  Of  all  these,  carbolic  acid  is  the  most 
certain  and  effectual. 

Constitutional  Treatment. — Nothing  is  more  important  for  a  practi- 
tioner in  the  treatment  of  morbid  states  than  to  have  in  his  mind  a  clear 
and  distinct  line  drawn  between  those  means  which  repair  the  ravages  of 
disease,  sustain  and  soothe  the  system  under  its  deleterious  influences,  and 
put  it  in  condition  to  allow  nature  to  strive  for  recovery  on  the  one  hand; 
and  those  which  by  some  specific  action  cure  the  affection  on  the  other. 
A  confusion  of  these  two  ideas  has  done  mischief  in  causing  hypermedi- 
cation,  and  in  creating  erroneous  conclusions  as  to  the  value  of  drugs. 
In  cancer  a  variety  of  drugs  has  at  various  times  since  the  birth  of  Christ, 
and  indeed  before  it,  been  vaunted  as  exerting  a  specific  influence.  As 
examples,  for  I  have  not  space  to  mention  one  tithe  of  the  whole,  mercury, 
iodine,  arsenic,  hemlock,  bromine,  gold,  silver,  and  other  drugs,  have  had 
their  day.  After  a  fair  trial  having  been  given  to  each,  but  one  conclu- 
sion can  be  drawn  by  a  writer  of  the  present  time,  namely,  that  we  appear 
to  be  as  far  removed  from  the  discovery  of  a  cure  for  cancer  as  were  the 
contemporaries  of  Hippocrates. 

"While  this  is  true  as  to  specific  medication,  a  much  more  gratifying 
statement  must  be  made  as  to  remedies  calculated  to  stay  the  progress  and 
combat  the  ravages  of  cancer. 

The  general  strength  should  be  maintained  by  fresh  air,  residence  in 
the  country,  generous  food,  alcoholic  stimulants,  iron,  and  bitter  tonics, 
while  the  mind  should  be  kept  cheerful  by  lively  company,  and  avoidance 
of  the  society  of  those  who  encourage  conversation  concerning  the  existing 
disease.  As  the  digestion  is  weak,  the  most  digestible  substances  should 
constitute  the  staple  diet,  and  very  often  a  patient  who  will  become  ema- 
ciated upon  solid  food  and  a  mixed  diet  will  improve  upon  the  exclusive 
use  of  milk,  beef-tea,  and  similar  substances.  So  marked  is  this  fact,  that 
the  milk  diet  strictly  adhered  to  has  been  regarded,  by  many  non-profes- 
sional persons,  as  a  means  of  cure  for  cancer. 

Among  bitter  tonics,  I  have  found  Huxham's  Tincture  an  excellent  one 
to  stimulate  the  appetite  and  sustain  the  strength,  and  for  the  impoverished 
blood-state  created  by  hemorrhage  the  hypophosphites  answer  an  excellent 
purpose. 

Extirpation  of  the  Uterus Of  late,  the  extirpation  of  the  entire  uterus 

for  malignant  disease  confined  to  it  has  not  only  been  advocated,  but 
repeatedly  practised.  The  procedure  which  has  been  followed  has  been 
that  of  Prof.  Freund,  of  Breslau,  the  greatest  advocate  of  the  operation. 
The  "Chicago  Medical  Gazette,"  quoting  from  "Schmidt's  Jahrbucher," 
gives  the  following  statistics  of  complete  uterine  extirpation  for  malignant 
disease  of  the  uterus.  Freund  has  performed  14  operations  with  8  deaths, 
5  recoveries,  1  incomplete  operation.  Of  the  five  recoveries  one  died  from 
a  return  of  the  cancer,  one  from  pleuritis,  and  a  third  is  now  suffering  from 


TREATMENT.  599 

a  return  of  the  cancer.  Of  the  remaining  25  operations  of  which  the 
results  are  known,  which  have  heen  recorded  by  various  operators,  19 
died,  5  recovered,  and  in  one  case  the  operation  was  incomplete.  Of 
these  five  successful  cases,  in  three  the  cancer  returned. 

The  procedure  of  Prof.  Freund  is  the  following.  An  incision  being 
made  through  the  median  line,  the  intestines  covering  the  uterus  are  held 
up  out  of  the  pelvis  by  means  of  a  soft  linen  cloth  soaked  in  warm,  car- 
bolized  water,  until  the  operation  is  finished.  One  thread  is  passed  through 
the  fundus  uteri,  and  another  through  the  peritoneum  of  the  anterior  part 
of  the  pelvis,  to  prevent  its  collapse,  and  held  by  assistants.  Each  broad 
ligament  is  now  ligated  in  three  portions,  the  upper  ligature  transfixes  the 
Fallopian  tube  and  the  ovarian  ligament,  the  middle  one  passes  through 
the  ovarian  ligament  by  the  side  of  the  upper  ligature  and  returns  through 
the  round  ligament ;  the  lower  pierces  the  round  ligament  and  is  carried 
twice  through  the  vaginal  wall — first  through  the  antero-lateral  part  of  the 
vaginal  roof  into  the  vagina,  and  then  back  through  the  postero-lateral  part 
of  the  vaginal  cul-de-sac  behind  the  base  of  the  lateral  ligament  into  Doug- 
las's pouch.  The  uterus  is  then  removed,  and  after  drawing  the  ends  of  the 
ligature  into  the  vagina  the  peritoneal  opening  is  closed,  and,  the  intestines 
having  been  replaced,  the  abdominal  incision  is  treated  as  after  ovariotomy. 

Freund1  has  more  recently  made  certain  modifications  in  his  operation. 
I.  To  avoid  accidental  detachment  of  the  peritoneum  from  the  anterior 
wall  of  the  pelvis  during  the  operation,  the  incision  through  the  perito- 
neum is  to  be  shorter  than  that  through  the  skin,  so  that  the  peritoneum 
at  the  inferior  extremity  of  the  wound  may  be  stitched  to  the  skin.  II. 
Instead  of  passing  a  looped  wire  through  the  body  of  the  uterus,  for  the 
purpose  of  steadying  it,  he  uses  the  fenestrated  ovariotomy  forceps.  III. 
By  means  of  a  trocar  needle  a  ligature  is  passed  from  the  peritoneal  cavity 
to  the  vagina  on  one  side  of  each  broad  ligament  and  then  from  the  vagina 
to  the  peritoneal  cavity  on  the  other  side.  This  ligature  is  made  to  enter 
and  to  leave  the  vagina  at  points  very  near  together  in  the  utero-vaginal 
attachment,  so  as  to  include  as  little  vaginal  tissue  as  possible.  This  liga- 
ture does  not  include  the  Fallopian  tubes,  the  ovarian  ligament,  or  the 
round  ligament.  It  is  tied  and  the  ends  are  cut  off.  IV.  To  distinguish 
between  the  ligatures  of  the  Fallopian  tubes,  of  the  ovarian  ligaments,  and 
of  the  round  ligaments,  he  attaches  to  the  end  of  the  superior  a  slender 
piece  of  metal,  to  the  next  below  a  shorter  piece,  to  the  other  none  at  all. 
This  also  facilitates  the  passage  of  the  ligatures  through  the  vaginal  wound. 
V.  He  passes  loops  through  the  peritoneal  flaps  to  facilitate  the  dissection 
of  the  uterus  therefrom.  VI.  When  the  dissection  along  the  anterior  wall 
of  the  uterus  is  nearly  complete,  he  makes  a  small  incision  from  the  vagina 
through  the  utero-vaginal  attachment,  and  dilates  this  incision  until  it  will 

1  Chicago  Medical  Gazette,  April  20,  1880. 


600  CANCER  OF  THE  UTERUS. 

admit  one  or  two  fingers  of  the  left  hand.  Then  passing  these  fingers 
through  this  opening  he  inserts  them  into  the  uterine  canal  to  facilitate 
the  handling  of  the  organ  during  the  remaining  part  of  its  extirpation. 

Such  is  Freund's  operation  for  ablation  of  the  uterus  affected  by  malig- 
nant disease.  Those  who  have  thus  far  performed  this  operation  for  ma- 
lignant disease  have  been  Freund,  Martin,  Mueller,  Olshausen,  Baum- 
gaertner,  Schroeder,  Winckel,  Kocks,  Crede,  Oelschlager,  and  Noeggerath. 
Schroeder1  declared  at  a  meeting  of  the  German  Gynecological  Society  in 
1878  that  if  five  times  out  of  six  the  disease  should  return,  he  would  still 
operate.  In  this  conclusion  he  will  find  few  conservative  surgeons  to 
agree  with  him.  Freund'4  operation  is  adhoe  sub  judice.  Time  will 
decide  as  to  its  value. 

At  the  risk  of  becoming  tedious  by  repetition,  I  offer  the  following 
resumt  of  the  methods  of  fulfilling  the  indications  in  treating  this  affection. 

1st.  Secure  cleanliness,  prevention  of  fetor,  and  diminution  of  hemor- 
rhage and  pain  by  the  free  use  of  warm  vaginal  injections  of  antiseptic 
and  astringent  character  such  as  the  following  : — 

R.  Acidi  carbolici  (sol.  sat.),  § ijss. 
Glycerins,  Oj. 
Alurainis  sulphatis,  ^xiv. 
Morphia?  sulphatis,  gr.  xvj. — M. 
S. — Add  one  tablespoonful  to  two  quarts  of  warm  water,  and  use  as  a  vaginal 
injection  morning  and  evening  by  Davidson's  or  the  fountain  syringe.2 

2d.  Give  an  abundance  of  food  which  the  system  can  appropriate,  at 
regular  intervals,  bearing  in  mind  that  nutrition  consists  in  the  introduc- 
tion into  the  blood,  not  into  the  stomach  alone,  of  nutrient  materials. 

3d.  Do  not  indulge  in,  what  appears  to  be  to  a  certain  order  of  medical 
mind,  the  grim  pleasure  of  making  a  fatal  prognosis.  As  long  as  possible 
let  the  patient  enjoy  the  "  pleasures  of  hope."  It  is  not  the  duty  of  the 
physician  to  hold  constantly  before  her  eyes  the  gloomy  picture  of  a  speedy 
and  certain  death  which  he  is  powerless  to  avert.  No  deception  should 
be  practised,  and  none  need  be,  for  these  patients  always  suspect  the  truth 
and  do  not  seek  to  be  informed.  Immediate  relatives  should  have  the 
facts  plainly  stated  to  them. 

4th.  Quiet  pain  by  the  systematic  use  of  opium  or  one  of  its  alkaloids. 
The  use  of  the  hypodermic  syringe  at  a  fixed  hour  every  day  is  the  most 
certain  and  frequently  the  most  agreeable  plan. 

5th.  If  possible,  remove  the  diseased  part  completely  by  surgical  means. 

6th.  If  complete  removal  be  impossible,  and  the  vagina,  bladder,  rectum, 
or  pelvic  tissues  be  involved,  as  a  rule  avoid  surgical  interference  entirely. 

1  Am.  Journ.  of  Obstetrics,  Jan.  1879. 

2  A  syringe  of  English  manufacture,  which  I  regard  as  superior  to  those  above 
mentioned,  has  just  been  introduced  here  under  the  name  of  the  syphon  enema 
syringe. 


TREATMENT.  601 

7th.  If  the  disease  be  confined  to  the  uterus,  and  complete  removal  be 
impossible,  practise  partial  removal  or  destruction  of  the  growth  by  gal- 
vano-cautery,  the  scissors,  scoop,  or  curette,  or  by  actual  cautery  or  fuming 
nitric  acid. 

8th.  If  the  affection  be  entirely  confined  to  the  uterus,  the  propriety  of 
its  complete  removal  by  laparotomy  should  be  considered.  This  opera- 
tion has,  however,  been  thus  far  too  little  tested  to  render  an  absolute 
decision  with  reference  to  the  propriety  of  its  adoption  possible. 

Although,  of  course,  there  is  a  great  deal  of  discomfort  and  of  suffering 
inherent  to  the  progress  of  this  dreadful  malady,  it  is  surprising  to  see  to 
how  great  an  extent  these  may  be  mitigated  by  forethought  and  intelli- 
gent attention  to  detail.  In  one  case  we  see  a  woman  suffering  almost 
constant  pain,  breathing  an  atmosphere  vitiated  by  sickening  odors,  asso- 
ciating with  persons  whose  every  word  and  look  are  productive  of  in- 
creased sadness  and  depression,  and  looking  forward  with  unvarying  gaze 
to  the  grave  as  an  issue  for  her  troubles,  scarcely  more  gloomy  than  her 
present  place  of  abode.  In  another  the  ability  and  care  of  the  physician 
have  changed  all  this.  The  patient  looks  forward  for  the  visit  of  her 
medical  attendant  with  the  certainty  that  a  full  dose  of  morphia  hypoder- 
mically  administered  will  give  her  twenty-four  hours  of  freedom  from 
severe  pain.  Experience  has  taught  her  that  the  antiseptic  injections 
which  she  employs  every  four  or  five  hours  have  the  unquestionable  power 
of  almost  entirely  annihilating  disagreeable  odors,  and  that  the  well-regu- 
lated circulation  of  air  and  the  repeated  flushing  of  one  chamber  during 
the  course  of  the  day  while  she  occupies  another  will  give  her  pure  and 
fresh  air  to  breathe.  She  recognizes  the  fact  that  some  influence  other 
than  her  own  has  surrounded  her  with  associates  who  prefer  exaggerating 
the  silver  lining  of  the  cloud  which  hangs  over  her,  to  contemplating  its 
gloom,  and  the  cultivation  of  thoughts  calculated  to  create  cheerful  resig- 
nation, quiets  and  sustains  the  mind.  Then,  too,  in  the  very  depths  of 
her  heart  flickers  still  a  faint  ray  of  hope.  The  worst  is  not  known  to 
her,  and  she  lives  in  comparative  comfort  until  the  closing  scene. 

There  is  a  peculiar  nervous  condition  which  develops  in  women,  which 
deserves  the  name  of  carcinophobia.  A  dread  of  cancer  suddenly  seizes 
the  woman,  either  from  some  physical  reason  like  the  recognition  of  some 
point  of  induration,  or  a  moral  one  like  the  recent  death  of  a  friend  from 
that  disease,  and  losing  all  reason  she  becomes  panic-stricken  to  a  degree 
which  renders  her  and  all  those  who  surround  her  utterly  wretched.  The 
assurances  of  the  physician  are  either  doubted  or  disregarded,  and  the 
unhappy  patient  falls  into  a  state  of  despondency  bordering  upon  acute 
hypochondriasis.  Some  years  ago  a  very  timid  and  sensitive  lady,  whose 
mother  had  died  of  cancer,  came  to  me,  from  one  of  the  largest  cities  of 
this  country,  by  the  advice  of  her  physician,  to  be  operated  upon  for  cancer 
of  the  cervix  uteri.     She  appeared  so  completely  dazed  by  the  announce- 


602  UTERINE    MOLES. 

ment  of  the  diagnosis  and  prognosis  on  the  part  of  her  medical  attendant, 
that  she  was  scarcely  aroused  by  the  statement  on  my  part,  that  she  had 
no  trace  of  cancer,  and  that  the  laceration  of  the  cervix  and  fungoid  de- 
generation, which  had  been  mistaken  for  it,  could  be  readily  and  certainly 
cured.  In  two  weeks  from  the  time  that  I  first  saw  her  she  was  seen  with 
me  by  Dr.  Choate,  and  was  removed  to  his  private  asylum  at  Pleasantville, 
where,  after  six  months'  residence,  she  entirely  recovered  from  a  mental 
aberration  which,  in  the  opinion  of  Dr.  Choate  and  myself,  was  wholly  due 
to  the  injudicious  announcement  to  her  of  an  incorrect  diagnosis. 


CHAPTER    XXXIX. 

DISEASES  RESULTING  FROM   RETENTION  AND  ALTERATION  OF  THE 
FCETAL  ENVELOPES. 

Uterine  Moles. 

Definition — By  this  term  is  meant  the  existence  in  the  cavity  of  the 
uterus  of  a  fleshy  mass  which  cannot  with  propriety  be  classed  among 
tumors  or  polypi,  and  which  consists  in  the  retention  of  a  part  or  the 
whole  of  the  foetal  shell,  or  of  the  placenta. 

The  appellation  of  mole  is  neither  elegant  nor  appropriate,  but  it  is 
sanctioned  by  use  for  so  great  a  length  of  time  that  it  is  difficult  to  alter, 
and  impossible  to  discard  it. 

History Ancient  medical  literature  teems  with  theories,  hypotheses, 

I  might  also  say  fables,  upon  this  subject.  It  would  be  unprofitable  even 
to  enumerate  the  extravagant  and  baseless  surmises  indulged  in  upon  it, 
but  as  an  example  I  will  mention  that  Aristotle,1  Hippocrates,  Galen,  and 
the  Latin  authors  regarded  moles  as  due  to  a  want  of  virtue  in  the  seminal 
fluid,  or  to  a  superabundance  of  menstrual  blood. 

A  certain  superstition  has  attached  to  them  even  in  modern  times;  thus, 
Capuron  quotes  Mahon  for  the  following  very  curious  assertion :  "  The 
housewives  believe  that  moles  not  only  take  the  forms  of  certain  animals, 
but  that  they  even  walk,  run,  fly,  try  to  hide  themselves,  even  to  re-enter 
the  womb  from  which  they  came  ;  indeed,  if  no  obstacle  be  offered  they 
will  kill  the  woman  just  delivered  of  them."  Levret  pointed  out  the  fact 
that  they  are  only  the  foetal  shell,  which  by  the  establishment  of  a  low 
grade  of  nutrition  continues  to  exist. 

Pathology As  the  foetus  passes  into  the  uterus  it  is  enveloped  by  its 

proper  membranes,  the  amnion  and  chorion,  and  these  are  surrounded  by 
a  prolongation  of  the  hypertrophied  mucous  lining  of  the  organ,  called  the 
decidua  reflexa.     Between  the  end  of  the  second  and  the  end  of  the  third 

1  Capuron,  Mai.  des  Femmes,  p.  268. 


DIFFERENTIATION.  603 

month  the  placenta  is  formed,  and  the  villi  of  the  chorion  not  engaged  in 
its  development  become  atrophied.  Before  that  time  the  foetal  shell  is 
quite  thick,  and  is  everywhere  in  close  communication  with  the  uterine 
walls. 

Many  adverse  influences  may  destroy  the  life  of  the  fetus,  and  generally 
as  a  result,  the  whole  of  the  products  of  conception  are  swept  away  by 
uterine  contraction.  But  sometimes  the  shell  of  membranes  clings  to  its 
attachment,  and  for  an  unlimited  period  holds  its  position  in  utero.  This, 
absorbing  nourishment  from  the  uterine  vessels,  becomes  to  a  certain  ex- 
tent organized,  and  constitutes  the  disease  under  consideration.  AVhen 
expelled  from  the  uterus  a  mole  is  usually  found  to  be  somewhat  ovoid  in 
shape,  and  to  resemble  the  product  of  conception  at  the  second  month.  It 
differs  from  this,  however,  in  its  dark  brown  color  and  apparent  lack  of 
vitality. 

Causes There  are  many  intrauterine  growths  and  collections  which, 

being  cast  off,  may  be  mistaken  for  moles,  as,  for  example,  masses  of  co- 
agulated blood,  polypi,  decidual  membranes,  etc.,  but  a  true  mole  never 
exists  except  as  a  result  of  conception. 

Symptoms. — The  condition  generally  announces  itself  by  these  symp- 
toms : — 

Menorrhagia  or  metrorrhagia ; 

Hypogastric  weight  and  uneasiness  ; 

Uterine  tenesmus  ; 

Slight  constitutional  disturbance  ; 

Cessation  of  signs  of  pregnancy. 
Physical  Signs — The  diagnosis  of  uterine  moles  is  very  obscure  and 
often  uncertain.  AVhen  a  patient  who  has  exhibited  all  the  signs  of  preg- 
nancy suddenly  ceases  to  do  so  and  presents  those  just  enumerated,  a  mole 
may  be  suspected.  Vaginal  touch  will  reveal  the  fact  that  the  uterus  is 
enlarged,  and  the  uterine  probe  may  assure  us  that  its  cavity  contains  some 
solid  substance,  but  the  removal  and  examination  by  the  microscope  of  a 
portion  of  the  mass,  will  alone  enlighten  us  as  to  its  character.  The  con- 
dition being  suspected,  the  cervix  should  be  dilated  by  tents,  and  uterine 
action  excited  by  ergot  in  order  to  settle  the  question. 

Differentiation — This  disease  may  be  confounded  with — 

Submucous  fibroid  ; 

Sarcoma  or  cancer  of  the  uterine  body ; 

Subinvolution. 
To  the  finger  passed  into  the  uterus,  a  fibrous  tumor  is  usually  hard, 
smooth,  and  resisting;  while  a  mole  is  soft,  spongy,  and  yielding  to  the 
touch,  but  this  may  prove  deceptive. 

Sarcoma  and  cancer  may  be  known  by  the  peculiar  sensation  yielded  to 
touch,  their  fetid  discharges,  the  constitutional  depreciation  attending 
them,  and  their  microscopical  characteristics. 


604  CYSTIC    DEGENERATION    OF    THE    CHORION. 

Subinvolution  demonstrates  upon  exploration  the  fact  that  the  uterus  is 
empty.  It  also  frequently  follows  delivery  at  full  term,  while  a  mole 
rarely  does  so. 

From  all  these  conditions  the  differentiation  may  be  positively  accom- 
plished in  one  way  and  one  way  only ;  dilatation  of  the  cervix,  removal 
of  a  small  portion  of  the  mass,  and  examination  of  this  by  the  microscope. 

Prognosis The  prognosis  is  favorable. 

Treatment — The  cervical  canal  should  be  fully  dilated  and  an  effort 
made  to  arouse  uterine  contraction  by  persistent  use  of  ergot.  Should 
this  fail,  the  mass  should  be  cautiously  removed  by  the  large  uterine 
scoop,  or  by  traction  by  means  of  the  placental  forceps. 

Cystic  Degeneration  of  the  Chorion,  or  Uterine  Hydatids. 

Definition The  chorion,  remaining  attached  to  the  uterine  walls  after 

expulsion  or  death  of  the  embryo,  sometimes  undergoes  a  peculiar  meta- 
morphosis which  receives  this  appellation.  True  hydatids,  that  is,  cysts 
due  to  the  presence  of  the  acephalocyst,  are  very  rarely  met  with  in  the 
uterus.  Their  extreme  rarity  may  be  judged  of  from  the  fact  that  Roki- 
tansky  declares  that  he  has  never  discovered  them  but  once.  Dr.  Graily 
Hewitt1  believes,  that,  when  they  exist  in  the  uterine  cavity,  it  is  prohable 
that  they  are  discharged  into  the  peritoneum  from  rupture  of  a  cyst  in  the 
liver,  and  then  pass  through  the  uterine  wall.  Not  only  do  the  grape-like 
cysts,  making  up  what  is  commonly  known  as  uterine  hydatids,  differ 
from  true  hydatids  in  absence  of  the  acephalocyst,  they  are  also  unlike 
them  in  their  appearance  and  formation.  The  former  consist  of  little  sacs 
in  a  series,  as  if  strung  together ;  the  latter  are  closed  sacs,  one  within 
another. 

Synonyms This  affection  has  been  described  under  the  names  already 

given,  and  under  those  of  vesicular  mole,  in  contra-distinction  to  fleshy 
mole  just  considered;  hydatidiform  mole;  and  hydatid  pregnancy.  In 
most  works  it  is  described  only  as  a  variety  of  mole. 

Pathology. — Remaining  in  connection  with  the  uterine  walls  after  the 
expulsion  of  the  foetus,  and  absorbing  nourishment  which  it  no  longer  ap- 
propriates, the  villi  of  the  chorion  undergo  a  kind  of  dropsical  swelling, 
which  results  in  the  grape-like  bodies  styled  hydatids. 

It  is  probable  that  after  the  end  of  the  third  month,  no  such  degenera- 
tion can  occur  in  the  secundines,  for  after  that  period  the  placenta  is 
formed,  the  villi  which  existed  at  its  site  become  vascular,  and  those  over 
ether  parts  of  the  surface  of  the  foetal  sac  undergo  atrophy.  It  is  true 
that  at  parturition  at  full  term,  masses  of  these  sacs  have,  in  rare  instances, 
been  expelled;  but  in  such  cases  it  is  probable  that  some  portion  of  the 
chorion  had  begun  to  degenerate  at  an  early  period  of  conception. 

1  Op.  cit.,  p.  75. 


PHYSICAL    SIGNS. 


005 


Causes. — we  know  of  no  influences  which  excite  this  form  of  degenera- 
tion in  a  retained  chorion. 

Fig.  238. 


Cystic  degeneration  of  chorion.     (Boivin  and  Duges.) 


Symptoms Sometimes  the  disease  demonstrates  its  presence  by  all 

the  signs  of  pregnancy,  abdominal  enlargement  being  one  of  the  most 
prominent.  Suspicion  of  the  existence  of  something  abnormal  is  very 
generally  excited  at  an  early  period  by  some  or  all  of  the  following 
signs  :— 

jSausea ; 

Discharge  of  clear  or  bloody  water  ; 

Hemorrhage  ; 

Uterine  tenesmus  ; 

Constitutional  disturbance  ; 

Discharge  of  little  cysts. 

Physical  Sicjns Vaginal  touch  will  reveal  the  uterus  enlarged,  and 

the  os  patulous,  as  if  the  cavity  of  the  organ  were  filled  with  something, 
and  conjoined  manipulation  will  prove  this  to  be  fluid  and  not  solid. 

If  with  these  signs  the  fact  could  be  ascertained   that  cysts  had  been 
discharged,  the  diagnosis  would  be  complete.     If  not,  the  cervix  should 


606  DYSMENORRHEA. 

be  dilated,  in  order  that  the  cavity  of  the  body  may  be  explored  by  touch, 
or  that  a  portion  of  the  mass  may  be  removed  for  inspection. 

Differentiation This  disease  might  very  readily  be  confounded  with — 

Pregnancy ; 

Polypus ; 

Sarcoma  or  cancer  of  the  body  of  the  uterus. 

From  pregnancy  it  could  generally  be  distinguished  by  the  very  rapid 
development  of  the  uterus,  the  presence  of  watery  and  bloody  discharges, 
and  the  absence  of  quickening,  ballottement,  and  other  signs  of  that  state. 

From  polypus  a  differentiation  could  readily  be  made  by  tents,  the 
uterine  sound,  and  the  microscope. 

Sarcoma  and  cancer  would  be  known  by  fetid  discharge,  great  constitu- 
tional decadence,  and  the  smaller  size  of  the  uterus  than  in  hydatids. 

Prognosis. — If  the  case  were  one  of  true  hydatids  due  to  the  acephalo- 
cyst,  the  prognosis  would  be  very  grave.  If  it  were  proved  to  be  one  of 
cystic  degeneration  of  the  chorion,  it  would  be  favorable. 

Treatment The  treatment  should  consist,  1st,  in  full  dilatation  of  the 

os  and  cervix  uteri  by  tents,  and  then,  if  necessary,  by  hydrostatic  dila- 
tors; and,  2d,  in  excitation  of  the  expulsive  powers  of  the  uterus  by  the 
free  use  of  ergot.  Should  this  drug  fail  in  establishing  the  desired  con- 
traction, a  large  scoop,  or,  if  possible,  the  hand,  should  be  gently  passed 
into  the  uterus,  and  the  mass  be  evacuated.  During  this  time,  should 
alarming  hemorrhage  occur,  it  should  be  controlled  by  the  tampon  and  by 
tannic  acid,  or  sulphuric  acid  given  internally. 

In  the  management  of  such  cases  the  difficulties  do  not  lie  in  the  way 
of  treatment,  but  in  that  of  diagnosis.  This  being  once  fully  established, 
treatment  becomes  simple. 


CHAPTER  XL. 

DYSMENORRHEA. 

We  have  now  arrived  at  the  most  appropriate  place  for  the  considera- 
tion of  the  derangements  of  the  process  of  menstruation  ;  and  first  among 
these  we  take  up  that  of  which  the  name  heads  this  chapter. 

The  process  of  menstruation,  by  which  the  human  female  discharges 
from  the  uterus  a  certain  amount  of  blood  once  in  every  lunar  month, 
depends  upon  three  phenomena  which  are  intimately  connected  together: 
1st,  the  spontaneous  escape  of  one  or  more  ovules  from  the  ovaries;  2d, 
engorgement  of  the  erectile  vascular  stratum  surrounding  and  supplying 
the  uterus ;    and,  3d,  rupture  of  the  vessels   supplying  the  endometrium, 


DYSMENORRHEA.  007 

together  with  rapid  desquamation  of  its  epithelial  cells.  Until  the  year 
1821,  when  Power  first  broached  the  subject,  the  connection  between 
ovulation  and  menstruation  was  unsuspected.  Even  then  it  was  not 
established  until  the  writings  of  Negrier  in  1840.  After  this  the  investi- 
gations of  Pouchet,  BischofT,  Coste,  and  Raciborski  carried  conviction  to 
the  minds  of  most,  and  caused  the  general  acceptance  of  the  theory.  There 
are  now  those  who  doubt  the  connection  of  the  two  phenomena,  but  I 
believe  that  I  am  correct  in  saying  that  they  are  decidedly  in  the  minority, 
and  that  the  ovular  theory  is  at  present  almost  universally  admitted. 
Tiiat  menstruation  sometimes  occurs  after  removal  of  both  ovaries  I  know 
by  experience  in  one  of  my  own  cases  of  ovariotomy,  and  Dr.  Ritchie1  has 
proved  that  it  may  occur  without  ovulation,  as  ovulation  often  takes  place 
without  it.  But  this  is  not  the  time  for  an  examination  into  the  merits 
of  the  lengthy  discussion  which  has  taken  place  concerning  the  subject. 
I  prefer  to  avoid  it,  and  to  express  the  view  which  I  believe  now  to  pre- 
vail, and  to  which  I  give  my  own  adherence. 

We  assume,  then,  that  the  extrusion  of  one  or  more  ovules  from  the 
ovaries,  which  takes  place  under  some  unknown  influence,  is  the  exciting 
cause  of  menstruation  ;  let  us  inquire  into  its  mode  of  action.  The  uterus 
is  surrounded  by  a  network  of  fine  and  tortuous  vessels,  which  envelop  it 
as  a  stratum  or  layer,  extending  through  the  broad  ligaments  to  the  ovaries. 
Outside  of  this  vascular  network  delicate  muscular  fibres,  extending  from 
the  uterus,  run,  encircling  its  vessels.  When  an  ovule  begins  to  approach 
the  circumference  of  the  ovary,  congestion  of  this  organ  occurs  in  conse- 
quence of  irritation.  This  irritant  effect  is  transmitted  to  the  muscular 
layer  surrounding  the  vascular  network  in  and  around  the  uterus.  Jt 
contracts,  impedes  sanguineous  flow,  and  causes  engorgement,  which  in 
the  membrane  lining  the  uterus,  and  in  all  probability  in  that  lining  the 
tubes,  causes  a  rupture  and  flow  of  blood  into  the  uterine  cavity.  This 
engorgement  constitutes  the  "erection"  alluded  to  by  Rouget  in  his 
"  Recherches  sur  les  Organes  erectiles  de  la  Femme."  Blood  flowing  from 
ruptured  vessels  collects  in  utero,  whence  it  flows  through  the  cervix  into 
the  vagina  and  from  thence  it  passes  out  of  the  vulva. 

When  all  the  elements  connected  with  this  process  are  in  a  perfectly 
normal  state,  it  occurs  without  creating  other  discomfort  than  a  sense  of 
fulness  about  the  pelvis,  slight  pain  in  the  back  and  loins,  and  a  general 
sense  of  lethargy.  But  if  an  abnormal  condition  should  exist,  either  in 
the  structure  from  which  the  blood  pours  into  the  uterus ;  in  any  of  the 
surrounding  parts  or  organs  which  undergo  congestion  ;  or  in  the  canal  by 
which  it  passes  into  the  vagina,  menstruation  often  becomes  excessively 
painful,  and  in  some  cases  undermines  the  health  by  the  intensity  of  suffer- 
ing which  it  induces.  This  state  receives  the  name  of  dysmenorrhea,  a 
term  derived  from  5dj,  difficult,  pqv,  a  month,  and  p«w,  I  flow. 

1  Ovarian  Physiology  and  Pathology. 


608  DYSMENORRHEA. 

Pathology Any   condition,   whether   general   or  local,   affecting   the 

structure  of  the  uterine  walls,  the  ovaries,  or  the  surrounding  areolar  or 
serous  tissues,  so  as  to  render  the  nerves  supplying  these  parts  morhidly 
sensitive,*  may  produce  pain  in  connection  with  the  first  part  of  the  pro- 
cess. Anything  impeding  the  escape  of  blood  from  the  uterus  or  vagina 
may  produce  it  by  interference  with  the  second  part.  For  example,  a 
general  condition  resulting  in  neuralgia  of  the  uterine  or  pelvic  nerves,  or 
a  local  inflammation  altering  their  state,  might  readily  create  pain  in  the 
first  stage,  while  either  a  natural  or  acquired  stricture  of  the  cervix  would 
probably  do  so  in  the  second. 

As  a  general  rule,  dysmenorrhea  is  due  to  one  or  more  of  the  three 
following  factors  :  1st,  a  depreciated  condition  of  the  constitution,  begin- 
ning usually  either  in  the  nervous  system  or  blood,  which  creates  a  ten- 
dency to  neuralgia  ;  2d,  an  abnormal  state  of  the  uterus  ;  or  3d,  a  diseased 
state  of  the  ovaries.  In  a  woman  in  whom  the  nervous  system,  the  uterus, 
and  the  ovaries  are  normal,  it  is  highly  improbable  that  this  condition 
would  ever  arise.  Every  practitioner  can  recall  numerous  instances  in 
which  any  one  of  the  three  conditions  mentioned  has  sufficed  to  establish 
it,  and  as  this  is  true  of  each  of  them  separately  it  is  more  so  of  a  combi- 
nation of  the  three. 

Every  case  should  be  examined  from  this  standpoint  in  practice,  and 
the  treatment  adopted  should  be  governed  by  the  discovery  of  the  existence 
of  one  or  more  of  these  conditions  as  causative  agents : — 

Varieties  of  Dysmenorrhea For  convenience  of  study,  dysmenorrhea 

may  be  divided  into  the  following  varieties  : — 
Neuralgic  dysmenorrhea ; 
Congestive  or  inflammatory  dysmenorrhea  ; 
Obstructive  dysmenorrhea ; 
Membranous  " 

Ovarian  " 

Seat  of  Pain  in  Dysmenorrhaea Upon  this  point  our  knowledge  is 

not  certain.  It  is  probable  that  in  the  first  three  varieties  the  pain  is 
seated  in  the  uterus,  in  the  ovaries,  or  in  the  cellular  tissue  or  peritoneum 
surrounding  the  pelvic  viscera.  Some  of  the  most  intractable  cases  with 
which  I  have  met  have  been  due  to  pelvic  peritonitis,  which,  even  after 
inflammatory  action  has  subsided,  has  left  the  nerves  supplying  these  parts 
in  so  sensitive  a  state  that  pain,  or  even  a  recrudescence  of  inflammation 
styled  menstrual  pelvic  peritonitis,  is  excited  in  them  by  the  process  of 
menstrual  congestion.  It  is  often  very  difficult  to  decide  as  to  the  exact 
seat  of  pain.  Even  a  physical  exploration  instituted  during  the  menstrual 
*>eriod  may  fail  to  enlighten  us. 

The  practitioner  who  regards  dysmenorrhea  as  a  disease,  and  applies 
to  every  case  a  uniform  plan  of  treatment,  will  rarely  meet  with  success 
in  its  management.     He  should  view  it  as  a  symptom  of  an  abnormal  con- 


NEURALGIC    DYSMENORRHEA.  G09 

dition  which  should,  as  far  possible,  be  discovered  and  removed.  Although, 
even  when  acting  thus,  cases  will  be  met  with  in  which  he  will  be  baffled, 
it  will  be  gratifying  to  perceive  how  rarely  these  will  occur.  The  great 
importance  of  differentiating  the  varieties  mentioned,  and  adopting  appro- 
priate plans  of  treatment,  calls  for  a  separate  study  of  each. 

Neuralgic  Dysmenorrhea. 

This  variety  depends  upon  no  appreciable  organic  disorder  of  the  uterus 
or  its  appendages,  but  merely  upon  a  peculiar  state  of  the  nerves,  which, 
under  the  stimulating  influence  of  congestion,  produces  pain. 

Causes. — There  are  many  agencies  Avhich  at  times  so  alter  the  healthy 
state  of  the  nerves  of  the  stomach  as  to  produce  in  them,  at  each  period 
of  digestion,  pain,  which  is  called  gastralgia  or  gastrodynia.  Similar 
agencies  may  occasion  neuralgia  of  the  nerves  of  the  eye,  or  of  those  sup- 
plying the  tissues  of  the  head  and  face.  In  like  manner  they  may  affect 
the  uterine  nerves  whenever  these  are  inordinately  excited  from  menstrual 
congestion.  The  same  patient  who  from  slight  excitement  or  fatigue 
develops  supra-orbital  neuralgia,  will  often,  from  the  same  causes,  suffer 
from  neuralgic  dysmenorrhoea. 

The  causes  which  generally  induce  it  are — 
The  neuralgic  diathesis ; 
Chlorosis  or  plethora : 

Certain  blood  states,  as  those  of  malaria,  gout,  and  rheumatism  ; 
Luxurious  and  enervating  habits  ; 

Habits  deteriorating  the  nervous   system,  as  onanism  or  excessive 
venery. 

Symptoms Pain  may  show  itself  before  the  flow  has  been  established, 

and  disappear  as  soon  as  it  comes  on ;  or  it  may  continue  with  varying 
intensity  throughout  the  duration  of  the  menstrual  discharge.  The  patient 
usually  complains  of  a  sharp,  fixed  pain  over  the  pelvis,  down  the  loins, 
or  in  some  distant  part  of  the  body.  I  once  saw  a  patient  who,  during 
each  period,  suffered  intensely  from  neuralgic  pain  on  the  outer  side  of  one 
little  finger,  and  another  who  before  the  flow  was  established  experienced 
for  several  days  a  violent  pain  at  the  root  of  the  nose. 

In  some  cases  the  pain  seizes  the  patient  very  suddenly,  and  becomes 
so  agonizing  in  character  as  to  render  her  almost  delirious.  She  will  toss 
wildly  upon  her  bed,  and  give  evidence  of  the  most  severe  physical  suf- 
fering. Then  in  a  few  hours  the  pain  will  almost  as  suddenly  abate,  and 
for  the  rest  of  the  menstrual  period  exist  only  in  very  moderate  degree. 

Differentiation — When  the  pain  is  felt  in  the  uterus,  it  presents  nothing 

expulsive  in  its  character  ;  the  flow  of  blood  is  steady,  and  not  interrupted; 

no  clots  are  discharged  by  spasmodic  efforts,  and  physical  examination 

discovers  no  obstruction.    These  facts  generally  distinguish  neuralgic  from 

39 


610  DYSMENORRHEA. 

obstructive  dysmenorrhoea,  though  sometimes  differentiation  is  very  dif- 
difficult. 

From  the  congestive  form  it  is  differentiated  by  absence  of  constitutional 
disturbance,  and  by  its  being  habitual  and  not  exceptional.  It  may  be 
distinguished  from  the  inflammatory  variety,  by  absence  of  the  ordinary 
signs  of  endometritis,  and  of  ovarian  and  periuterine  inflammation.  There 
is  also  absence  of  leueorrhoea  and  pain,  as  well  as  of  the  physical  signs  of 
inflammation,  in  the  intervals  of  menstruation. 

Prognosis If  a  patient  affected  by  neuralgic  dysmenorrhoea  be  able 

and  willing  to  effect  a  decided  alteration  in  her  mode  of  life,  the  prospect 
of  recovery  is  good.  Should  no  such  change  be  attainahle,  it  is  decidedly 
unfavorable. 

Treatment The  first  duty  of  the  physician  should  be  to  discover  the 

cause  of  the  development  of  neuralgia  in  the  performance  of  the  menstrual 
function,  and  the  second  to  endeavor  to  remove  this.  Neuralgia  of  the 
face  and  head  is  rarely  a  primary  affection,  and  consequently  resists  reme- 
dies directed  especially  to  it.  It  generally  results  from  some  focus  of  irri- 
tation, as,  for  example,  a  decayed  tooth,  or  a  plug  of  hard  wax  in  the  ear, 
or  from  some  blood  poisoning ;  and  when  the  cause  is  removed  it  disap- 
pears. So  with  the  disorder  which  we  are  considering.  If  the  rheumatic 
or  gouty  diathesis  exist,  it  should  be  treated  by  colchicum,  guaiac,  and 
vapor  baths.  The  skin  should  be  kept  warm  and  active  by  wearing  flan- 
nel over  the  whole  body  in  winter,  and  a  mild,  equable  climate  should  be 
chosen  during  the  cold  months  of  the  year.  Should  a  delicate  state  of  the 
nervous  system  have  been  engendered  by  habits  of  luxury,  indolence,  or 
dissipation,  the  patient  should  be  sent  to  the  country,  where  an  out-of-door 
life,  horseback  exercise,  early  hours  of  retiring,  and  plain,  wholesome  food, 
may  exert  a  decidedly  alterative  influence.  Chlorosis  and  plethora  should 
be  treated,  the  one  by  ferruginous  and  nervous  tonics,  fresh  air,  food,  and 
cheerful  surroundings  ;  the  other  by  strict  diet,  venesection,  cathartics, 
and  other  depletory  means.  Malarial  toxaemia  should  be  treated  by  change 
of  residence,  quinine,  and  iron.  A  sea  voyage  will  often  accomplish  an 
excellent  result  in  neuralgic  dysmenorrhoea  by  its  alterative  influence, 
whatever  be  the  cause  of  the  neuralgic  state,  and  the  same  may  be  said  of 
surf  bathing. 

In  addition  to  these  general  means,  benefit  may  be  obtained  from  the 
use  of  some  which  are  local.  The  occasional  passage  to  the  fundus  of  the 
uterus  of  a  uterine  sound,  the  retention  in  utero  of  the  galvanic  pessary, 
which  will  be  described  when  speaking  of  amenorrhcea,  the  use  of  tents, 
and  the  systematic  employment  of  the  continuous  or  galvanic  current,  one 
pole  over  the  sacrum  or  against  the  cervix  and  the  other  over  the  hypo- 
gastrium,  will  often  prove  very  serviceable. 

Parturition  often  accomplishes  an  excellent  result,  and  in  many  cases 
cures  the  affection  entirely. 


CONGESTIVE    OR    INFLAMMATORY    DYSMENORRHEA .       611 

Besides  these  means  there  are  certain  anti-neuralgic  remedies  which  :iet 
more  or  less  as  specifics  in  this  form  of  dysmenorrhoea.  Foremost  amongst 
these  is  apiol,  a  yellowish,  oily  suhstance,  obtained  from  the  petroselinum 
sativum  by  the  action  of  alcohol  and  filtration  with  animal  charcoal.  It 
is  prepared  by  Joret  and  Ilomolle,  of  France,  in  the  form  of  capsules,  and 
is  sold  by  druggists  throughout  this  country.  The  dose  of  these  is  one 
capsule  night  and  morning  during  menstruation.  The  tincture  of  can- 
nabis indica,  in  doses  of  twenty-five  drops  every  fourth  hour  while  pain  is 
severe,  is  also  beneficial,  as  is  also  the  hydrate  of  chloral  in  ten  grain 
doses  every  eight  hours.  Where  a  spasmodic  element  appears  to  exist  in 
addition  to  the  neuralgic,  suppositories  of  butter  of  cocoa  containing  each 
a  quarter  of  a  grain  of  extract  of  belladonna  will  often  give  great  relief; 
they  should  not  be  repeated  oftener  than  once  in  every  eight  hours.  Under 
these  circumstances,  too,  great  benefit  will  often  follow  the  use  of  enemata 
of  tincture  of  assafoetida,  two  to  three  drachms  in  a  gill  of  warm  water, 
or  of  ten  grain  doses  of  chloral  dissolved  in  half  a  pint  of  warm  gruel. 
Placing  the  patient  in  a  very  warm  general  bath,  for  from  twenty  to  thirty 
minutes,  is  likewise  often  productive  of  great  relief. 

Congestive  or  Inflammatory  Dysmenorrhoea. 

Definition — At  each  menstrual  epoch  an  active  congestion  occurs  in 
the  mucous  membranes  of  the  Fallopian  tubes  and  uterus  as  well  as  in  the 
ovaries,  and,  probably,  to  a  less  degree  in  all  the  pelvic  tissues.  When 
any  abnormal  influence  renders  this  excessive,  it  naturally  produces  pain 
in  the  nerves  intervening  between  the  distended  vessels.  This  excessive 
hyperemia,  which  may  result  from  a  mechanical  cause,  as  displacement 
of  the  uterus,  or  from  a  vital  cause,  as  the  peculiar  condition  which  we 
know  as  inflammation,  gives  rise  to  a  variety  of  painful  menstruation 
which  has  been  styled  congestive  or  inflammatory,  and  which  has  been 
synonymously  styled  accidental  in  contra-distinction  to  those  forms  which 
are  habitual. 

The  state  of  inflammation  which  so  alters  the  condition  of  the  nerves 
immediately  affected  by  ovulation  or  menstruation,  may  exist  in  or  around 
the  uterus,  in  the  peritoneum  covering  it,  in  the  ligaments  which  sustain 
it,  or  in  the  areolar  tissue  of  the  pelvis. 

In  a  great  many  cases  inflammation  of  the  uterine  mucous  membrane 
is  the  cause  of  this  form  of  dysmenorrhoea.  The  existence  of  disease  in 
this  part  causes,  perhaps,  little  pain  until  the  erythism  engendered  by 
menstruation  occurs.  Then  great  local  excitement  takes  place  and  dys- 
menorrhoea shows  itself. 

Causes It  may  result  from  almost  any  pelvic  inflammation,  or  from 

any  influence  which  exaggerates  and  prolongs  the  congestion  excited  by 
ovulation.     Chief  among  these  may  be  mentioned — 


G12  DYSMENORRHEA. 

General  plethora ; 

Exposure  to  cold  and  moisture  ; 

Sudden  mental  disturbance ; 

Sluggishness  of  portal  circulation  ; 

Displacement  of  the  uterus  ; 

Fibrous  tumors; 

Areolar  hyperplasia; 

Endometritis  ; 

Periuterine  cellulitis ; 

Pelvic  peritonitis. 
Some  of  these  causes,  even  without  exciting  true  inflammation,  may 
keep  up  a  state  of  hyperaemia  in  the  uterine  vessels,  which,  being  aug- 
mented at  menstrual  epochs,  creates  pressure  upon  the  neighboring  nerves 
and  consequently  pain. 

Symptoms A  patient  who  has  previously  menstruated  painlessly  is 

seized  during  a  period  with  severe  pelvic  pain  accompanied  by  diminution 
or  cessation  of  the  discharge  and  considerable  constitutional  disturbance. 
The  pulse  becomes  full  and  rapid,  the  skin  hot  and  dry,  and  the  eyes  suf- 
fused. There  is  severe  pain  in  the  head,  with  nervousness,  restlessness, 
and  sometimes,  though  rarely,  a  little  delirium.  There  may  be  in  addi- 
tion rectal  and  vesical  tenesmus  and  diarrhoea.  In  cases  in  which  a  local 
inflammation  exists,  as  the  flow  begins,  or  before  that  time,  the  patient 
suffers  from  dull,  heavy,  fixed  pelvic  pain,  which  lasts  until  the  process  is 
ended,  and  often  even  after  it  has  done  so. 

Differentiation. — If  the  attack  be  due  to  hyperaemia  merely,  without 
inflammation,  the  constitutional  disturbance  and  suddenness  which  char- 
acterize it  will  mark  its  difference  from  the  neuralgic  and  obstructive 
forms,  as  the  absence  of  signs  of  inflammation  in  the  intervals  will  do 
from  the  inflammatory.  If  it  be  due  to  the  influence  of  existing  pelvic 
inflammation,  it  will  usually  be  marked  by  pain  during  the  inter-menstrual 
periods,  difficult  locomotion,  fatigue  after  exertion,  leucorrhoea,  etc. 

Prognosis. — This  will  depend  upon  the  prognosis  of  the  condition  which 
has  given  rise  to  it.  If  that  can  be  removed,  the  dysmenorrhoea,  which 
is  one  of  its  symptoms,  will  disappear;  if  not,  it  will  continue  without 
material  diminution.  If  the  cause  of  the  symptoms  be  a  fibrous  tumor, 
pelvic  peritonitis  or  periuterine  cellulitis,  or  even  an  irremediable  displace- 
ment, the  probability  of  relief  is,  of  course,  not  at  all  great. 

Treatment. — As  in  the  neuralgic  variety,  the  source  of  the  evil  should 
be  carefully  ascertained  before  remedial  measures  are  adopted.  If  it  be 
due  to  plethora,  the  lancet,  cathartics,  strict  diet,  exercise,  and  fresh  air 
will  be  indicated.  Should  the  attack  be  accidental  and  have  occurred 
from  exposure  to  cold  and  moisture,  opiates,  diaphoretics,  and  sedatives 
will  give  speedy  relief.  In  case  a  sluggishness  of  the  portal  circulation 
exists,  this  should  be  stimulated  to  greater  energy  by  mercurial  cathartics 


OBSTRUCTIVE    DYSMENORRHEA.  613 

and  a  change  in  the  habits  of  life  from  sendentary  to  active.  A  displaced 
uterus  is  often  kept  in  a  constant  state  of  congestion,  which  can  be  relieved 
only  by  properly  sustaining  the  organ.  This,  according  to  my  experience, 
is  the  most  frequent  of  all  the  causes  for  congestive  dysmenorrhcca.  In 
some  cases  a  slight  degree  of  retroversion  or  anteversion  will  produce  it, 
while  in  others  direct  descent  will  be  found  to  be  its  cause.  In  many  of 
these  cases  it  will,  upon  recognition  of  the  displacement,  be  scarcely 
credited  by  the  practitioner  that  it  is  sufficient  to  be  productive  of  the 
result.  Yet  replacement  of  the  uterus,  and  removal  of  superincumbent 
weight  by  means  of  a  skirt  supporter  and  abdominal  pad,  will  give  such 
complete  relief  as  to  put  all  doubts  at  rest.  If  a  fibrous  tumor  be  the 
cause,  a  cure  will  depend  upon  its  susceptibility  of  removal. 

Should  any  local  inflammation  be  discovered  as  the  cause  of  the  evil, 
this,  and  not  one  of  its  many  results,  should  be  the  subject  of  treatment. 

Obstructive  Dysmenorrhcea. 

If,  after  the  collection  of  blood  in  the  uterus,  any  obstruction  exist 
which  prevents  its  escape  into  and  through  the  vagina,  a  violent  spasmo- 
dic pain  is  excited  which  often  amounts  to  uterine  tenesmus.  To  this 
form  of  painful  menstruation  the  name  of  obstructive  dysmenorrhea  has 
been  applied.  The  obstruction  may  exist  in  the  os  or  cervix  uteri,  in  the 
vagina,  or  at  the  vulva,  where  that  canal  is  partially  closed  by  the  hymen. 
Pathology. — If  any  organ  be  filled  with  fluid  beyond  the  point  of  toler- 
ance, as,  for  example,  the  bladder,  stomach,  or  large  intestine,  violent 
contractions  of  the  distended  fibres,  which  make  up  its  walls,  are  excited, 
and  spasmodic  efforts,  which  have  received  the  name  of  tenesmus,  are 
established.  If  evacuation  result  from  these,  relief  is  obtained ;  if  not, 
contractions  continue  for  a  long  time.  When  occurring  in  the  uterus, 
they  present  the  symptoms  which  characterize  the  affection  which  now 
engages  us. 

Causes — The  special  causes  of  such  obstruction  are — 

Congenital  or  acquired  contraction  of  the  cervical  canal ; 

Flexion  or  version  of  the  uterus  ; 

Vaginal  stricture  ; 

Small  polypus  in  utero  ; 

Obturator  hymen  ; 

A  fibroid  in  the  parenchyma  of  the  neck. 
Any  one  of  these  causes  may  produce  the  result  by  partially  occluding 
the  cervical  canal,  so  as  to  allow  of  the  escape  of  fluid  imperfectly  and 
painfully.  Contraction  of  the  cervix  may  be  congenital,  or  may  result 
from  inflammation  of  the  mucous  lining  of  the  canal,  or  diminution  of  its 
calibre  by  contraction  of  the  parenchyma,  from  the  use  of  strong  caustics 
within  the  os,  or  other  cause.     The  last  cause  is  a  prolific  one,  the  con- 


C14  DYSMENORRHEA. 

dition  commonly  resulting  from  the  passage  of  the  actual  cautery  or 
potassa  cum  calce  into  the  canal  of  the  cervix.  Flexion  obstructs  the 
canal  by  creating  an  angle  in  its  course.  Let  a  tube  of  gutta-percha  be 
slightly  curved  and  no  obstruction  will  exist,  but  if  it  be  sharply  bent 
upon  itself  complete  occlusion  will  occur.  Versions  much  more  rarely 
produce  the  difficulty,  but  sometimes,  the  os  being,  by  reason  of  the  dis- 
placement, pressed  very  firmly  against  one  wall  of  the  vagina,  a  partial 
obstruction  is  produced. 

Some  time  ago  a  young  girl  presented  herself  at  my  clinique,  at  the 
College  of  Physicians  and  Surgeons,  declaring  that  at  every  menstrual 
epoch  she  suffered  from  the  most  intense  bearing-down  pains,  which  ex- 
hausted her  greatly.  Upon  examination  I  found  a  partial  closure  of  the 
vagina,  the  result  of  sloughing  during  typhus  fever,  which  had  produced 
an  accumulation  of  blood  above  it.  This  excited  uterine  contraction,  and 
each  effort  caused  the  expulsion  of  a  small  amount  of  the  fluid  collected 
above  the  stricture.  In  like  manner  the  hymen  may  prevent  free  escape 
and  produce  uterine  tenesmus. 

Sometimes  a  small  polypus  comes  down  to  the  os  internum  and  rests 
upon  it,  obstructing  the  egress  of  fluid,  but  permitting  the  passage  of  a 
probe  into  the  uterine  body.  It  acts  upon  the  principle  of  the  ball  valve, 
and  by  so  doing  produces  the  worst  features  of  obstructive  dysmenorrhea. 

Symptoms After    menstruation    has   continued   for  some   hours,  and 

sufficient  blood  has  been  collected  in  the  uterus  to  distend  it,  a  severe 
spasmodic  pain  occurs  over  the  pelvis,  which  has  been  styled  "uterine 
colic."  This  rapidly  passes  into  a  violent  expulsive  effort  like  the  con- 
tractions attending  miscarriage,  which  in  time  causes  the  passage  of  a 
certain  amount  of  blood.  Then  severe  pain  ceases  for  a  time,  until  further 
distention  and  obstruction  occur,  when  the  process  by  which  the  uterus 
empties  itself  is  repeated. 

It  will  be  clear  to  the  observer  that  the  difficulty  develops  itself  by 
three  steps: — 

1st.  Some  obstruction  causes  a  collection  of  blood  in  the  uterus; 

2d.  This  excites  uterine  contraction  by  distention  ; 

3d.  Uterine  contraction,  to  a  limited  degree,  frees  the  uterus  and  gives 
ease. 

This  is  the  pathology  of  the  condition,  whether  the  obstruction  exist 
in  the  vagina,  at  the  vulva,  or  in  the  cervical  canal.  If  it  exist  at  the 
last  point,  the  efforts  of  the  uterus  will  generally  expel  a  small  clot,  and 
then  a  gush  of  imprisoned  blood  will  follow,  much  to  the  patient's  relief. 

Differentiation. — The  symptoms  just  related  are  so  marked  and  decided 
that  little  difficulty  will  generally  be  experienced  in  determining  as  to  the 
pathology  of  the  case.  Before  such  a  decision  is  arrived  at,  however, 
physical  exploration  will  usually  place  the  matter  beyond  a  doubt.  The 
absolute   obstruction  may  generally  be  demonstrated  by  difficulty  in  the 


TREATMENT    OF   CERVICAL    CONSTRICTION.  G15 

introduction  of  a  probe  into  the  cavity  of  the  uterus.  Should  the  obstruc- 
tion exist  in  the  vagina,  the  finger  will  detect  it,  and,  if  in  the  cervix, 
the  probe  will  do  so  with  almost  as  great  precision. 

It  cannot  be  denied,  however,  that  in  exceptional  cases  a  degree  of 
constriction  at  the  internal  os  which  will  admit  the  sound  may,  by  some 
spasmodic  action  occurring  at  menstruation,  offer  an  obstruction  to  escape 
of  blood.  Indeed,  I  feel  that,  in  all  the  varieties  of  dysmenorrhea,  spasm 
of  the  fibres  of  the  os  internum  plays  a  much  more  important  role  than  is 
generally  appreciated.  It  is  this  fact  which  explains  the  occurrence  of 
severe  pain  at  certain  periods,  while  at  others  there  is  little  or  none.  In 
some  women  there  appears  to  be  a  regularity  about  this  irregularity,  the 
pain  occurring  without  assignable  reason  every  second  month. 

Prognosis This  will  depend  entirely  upon  our  ability  to  overcome  the 

mechanical  obstacle.  Should  it  not  be  possible  to  remove  this,  the  con- 
stantly repeated  distention  of  the  uterine  cavity  and  consequent  effort  re- 
quired for  emptying  it,  will  frequently  result  in  endometritis.  If  uterine 
displacement  exist,  it  should  be  treated  by  mechanical  means ;  any  nar- 
rowing of  the  vagina  should  be  overcome  ;  and  if  possible  any  obstructing 
neoplasm  removed.  If  the  indication  in  a  given  case  can  be  completely 
fulfilled,  the  prognosis  is  good,  but  not  otherwise. 

Treatment  of  Cervical  Constriction Should  it  be  discovered  that  the 

cause  of  difficulty  consists  in  congenital  or  acquired  constriction  of  the 
cervical  canal,  the  condition  may  be  remedied  by  two  methods,  dilatation 
and  incision,  the  means  for  accomplishing  which  may  be  thus  presented  at 
a  glance : — 

Dilatation. 

By  sounds ; 

By  tents  ; 

By  expanding  instruments. 
Incision. 

Simpson's  method  ; 

Sims's  method ; 

Combined  method. 
If  the  constriction  be  due,  as  it  very  commonly  is,  to  flexion  forwards 
of  the  body  or  neck  of  the  uterus,  the  point  of  stricture  will  usually  be 
found  near  the  os  internum  ;  if  it  be  due  to  congenital  deformity  without 
flexion,  it  will  usually  be  found  at  the  os  externum  ;  while  if  an  escharotic 
have  created  the  difficulty,  the  entire  length  of  the  canal  may  be  found 
deficient  in  calibre. 

About  the  year  1832,  Dr.  Mackintosh,  of  Edinburgh,  established  the 
practice  of  dilating  the  constricted  cervical  canal  by  metallic  rods,  as  is  done 
in  stricture  of  the  urethra.  His  plan  was  to  introduce  a  very  small  sound, 
leave  it  for  a  short  time  in  position,  and  then  follow  it  by  others  gradually 
increasing  in  volume.     He  declares,  in  reporting  upon  the  practice,  that 


616  DYSMENORRHEA. 

out  of  twenty-seven  cases,  twenty-four  cures  were  effected.  The  sounds 
by  which  dilatation  may  be  best  accomplished  are  graduated  ones  of  metal 
of  three  or  four  sizes.  Those  of  Kammerer  are  very  convenient.  Dila- 
tation by  their  means  should  be  slowly  and  cautiously  accomplished.  A 
sound  being  passed  should  be  left  in  position  for  several  minutes,  and  upon 
its  removal  another  should  be  inserted,  until  the  distention  deemed  prac- 
ticable at  one  sitting  is  attained.  There  can  be  no  question  as  to  the 
efficacy  of  this  plan,  though  it  is  probable  that  some  of  the  cases  relieved 
by  Dr.  Mackintosh  were  instances  of  neuralgic  and  not  obstructive  dys- 
menorrhea. 

When  this  method  is  to  be  adopted  the  patient  should  be  anaesthetized, 
and  by  means  of  graduated  sounds  the  cervix,  which  has  been  held  by  a 
tenaculum,  should  be  dilated  by  the  application  of  a  little  force. 

The  same  result  may  be  accomplished  by  the  use  of  tents  of  sea-tangle 
or  tupelo,  but  the  danger  attending  this  method  should  always  be  consi- 
dered before  it  is  selected. 

Another  method,  which  has  been  adopted  with  advantage  in  many  cases, 
consists  in  the  dilatation  of  the  constriction  by  means  of  expanding  instru- 
ments.    One  of  the  best  of  these  is  shown  in  Fig.  239. 

Fig.  239. 


46°=^ 


Priemly's  dilator  for  the  cervix. 


A  modification  of  Holt's  stricture  dilator  is  likewise  employed  for  this 
purpose,  and  every  surgical  instrument  maker's  shop  will  display  many 
others. 

Ball  of  Brooklyn,  and  Ellinger  of  Germany,  accomplish  complete  cer- 
vical dilatation  by  the  use  of  powerful  divulsors,  which,  the  patient  being 
anaesthetized,  stretch  the  canal  widely  open  at  the  expense  of  the  tissues 
which  form  it.  I  have  seen  the  operation  performed,  and  must  say  that 
it  is  to  all  appearances  shockingly  brutal,  and  seems  to  be  a  dangerous  pro- 
cedure. Excellent  reports  are  nevertheless  made  of  its  results,  and  the 
day  has  passed  when  any  one  should  allow  prejudice  to  bias  his  judgment 
in  reference  to  any  surgical  procedure,  the  danger  of  which  may  possibly 
exist  only  in  appearance. 

Although  a  great  deal  has  been  said  by  high  authority  of  late  years 
against  dilatation  and  in  favor  of  incision  in  these  cases,  an  opposite  posi- 
tion was  taken  by  many  prominent  men  in  a  debate  before  the  American 
Gynecological  Society  in  1878.  Schultze,  of  Jena,  combines  the  use  of 
laminaria  tents  with  decided  dilatation  by  means  of  the  instrument  shown 
in  Fig.  240.     After  full  dilatatiou  by  tents  of  laminaria,  the  dilated  cer- 


TREATMENT    OF    CERVICAL    CONSTRICTION. 


017 


vix  is  still  further  distended  by  the  two-branched  instrument  just  shown. 
The  entire  procedure  is  accomplished  under  Lister's  antiseptic  method. 


Fig.  240. 


Schultze's  dilator. 

I  have  satisfied  myself  that  the  success  of  these  methods,  like  that  of  the 
cutting  operations  adopted  for  the  same  purpose,  depends  not  on  the  way 
in  which  they  are  performed,  but  upon  the  lengthy  maintenance  of  dilata- 
tion after  them  by  retention  in  the  cervical  canal  of  a  glass  plug  an  inch 
and  a  half  or  an  inch  and  three-quarters  long.  By  this  the  dilatation  ob- 
tained by  operation  is  perpetuated  until  a  permanently  free  cervical  canal 
is  secured.  It  matters  not  whether  the  original  distention  was  accom- 
plished by  one  method  or  by  another. 

Whatever  plan  be  adopted,  the  antiseptic  method,  with  the  exception  of 
the  spray,  should  be  observed  strictly. 

In  1843,  Prof.  Simpson,  of  Edinburgh,  advocated  and  practised  cutting 
through  the  walls  of  the  cervix,  and  thus  gaining  space  without  dilatation. 
He  employed  a  single-bladed  hysterotome,  represented  in  Fig.  241. 

Fig.  241. 


Simpson's  hysterotome. 

This  instrument  is  introduced  without  a  speculum,  the  patient  lying  on 
her  left  side.  The  hysterotome,  with  its  blade  concealed,  is  guided  by 
the  index  finger  up  to,  and  if  necessary,  as  is  very  rarely  the  case,  through 
the  os  internum.  If  the  cervical  canal  be  too  small  to  admit  it,  previous 
dilatation  should .  be  practised  by  tents.  Being  placed  in  position  the 
blade  is  thrown  out,  the  force  being  increased  as  it  is  withdrawn  to  the  os 
externum.  By  thus  increasing  the  pressure  upon  the  handle  of  the  blade, 
the  incision  is  made  wider  at  the  lower  than  at  the  upper  end  of  the  canal. 
The  instrument  is  then  reintroduced  and  the  other  side  incised  in  a  similar 
manner,  and  the  surface  is  brushed  over  with  the  solution  of  persulphate 
of  iron. 

To  accomplish  the  incision  of  both  sides  simultaneously,  a  number  of 


G18 


DYSMENORRHEA. 


double  hysterotomes  have  been  devised  with  two  blades  instead  of  one. 
That  of  Dr.  Greenhalgh,  of  London,  has  become  popular.  A  very  simple 
one  devised  by  Mr.  Stohlmann,  of  this  city,  is  represented  in  Fig.  242, 
and  a  very  excellent  hysterotome  is  that  of  White,  shown  in  Fig.  243. 


Fig.  242. 


Stoblmann's  hysterotome. 

Since  Dr.  Simpson  introduced  this  plan  of  treatment,  several  modifica- 
tions of  it  have  been  recommended,  but  very  little  improvement  had  been 
attained  until  the  introduction  of  Dr.  Marion  Sims's  method.  This  con- 
sists in  exposing  the  parts  fully  to  view  and  replacing  the  bistourie  cache 

Fig.  243. 


White's  hysterotome. 


by  the  knife  or  scissors,  guided  by  the  eye  of  the  operator.  It  is  an  axiom 
that  whatever  secures  clearness  of  observation  conduces  to  good  surgery. 
Darkness  and  bad  surgery  go  hand  in  hand.  For  this  reason  Sims's 
method  is  far  superior  to  Simpson's.  It  puts  this  operation  on  a  level 
with  those  practised  in  other  departments  of  surgery,  and  lifts  it  out  of  the 
field  of  uncertainty. 

The  operation  which  I  proceed  to  describe  is  that  which  I  perform,  and 
is  almost  identical  with  the  original  operation  of  Sims.  The  vagina  having 
been  thoroughly  syringed  out  with  a  1  to  30  solution  of  carbolic  acid,  the 
patient  is  placed  in  Sims's  position  and  his  speculum  is  introduced.  The 
vagina  is  then  filled  with  carbolized  water,  which  remains  in  it  all  through 
the  operation,  and  if  the  operator  is  careful  the  operation  may  be  performed 
almost  under  water,  so  thoroughly  does  it  bathe  the  vaginal  cervix. 

The  cervix  is  now  drawn  well  down  by  a  tenaculum,  and,  by  means  of 
a  long,  slender  bistoury,  like  that  of  Sims,  an  incision  is  made  from  and 
a  little  above  the  os  internum  uteri  through  the  cervical  tissue  and  through 
the  os  externum,  so  as  to  cut  entirely  through  the  vaginal  portion  of  the 
cervix  at  its  lowest  part.  Then  the  other  side  is  similarly  cut,  and  a  glass 
plug  one  and  a  half  inches  long  is,  as  soon  as  active  hemorrhage  has 
ceased,  pushed  by  the  finger  through  the  severed  os  internum,  and  kept 


TREATMENT.  619 

in  place  by  a  tampon.     The  upper  portion  of  this  has  been  saturated  with 
the  following  antiseptic  and  astringent  solution : — 

I£.  Aluuiinis  sulph.  5j- 
Zinci  sulpli.  3j- 
Cupri  sulpli.  3j- 
Glycerin®,  Jj. 
Aquae,  Oj. — M. 

The  lower  portion  of  the  tampon  consists  merely  of  carbolized  cotton. 

There  is  very  little  danger  from  hemorrhage  when  the  cervix  is  not  cut 
up  to  the  vaginal  junction,  and  the  patient  is  carefully  watched. 

The  tampon  is  removed  in  thirty-six  hours,  the  vagina  thoroughly  car- 
bolized, and  a  pessary,  small  and  loosely  fitting,  like  that  shown  in  Fig.  1 70, 
is  put  in  position.  After  this,  carbolized  vaginal  injections  should  be  used 
twice  in  every  twenty-four  hours,  the  patient  is  kept  in  bed  for  a  fortnight, 
and  the  glass  stem  and  pessary  are  kept  in  position  for  two  months.  The 
former  does  not  interfere  with  menstruation,  and  when  it  is  removed  the 
healing  process  has  finished,  and  contraction  is  much  less  likely  to  occur 
than  it  would  be  if  no  stem  were  employed,  or  one  were  kept  in  place  for 
ten  days  only. 

The  influence  which  invalidates  this  operation  is,  I  am  convinced,  the 
contraction  which  attends  the  reparative  process.  Let  this  process  go  on 
to  completion,  contraction  being  rendered  impossible,  and  a  full  and  wide 
canal  will  be  secured  as  a  result  of  the  operation.  The  stem  goes  only 
within  the  os  internum ;  not  into  the  body  of  the  uterus ;  and  I  have 
seldom  seen  it  do  harm;  nevertheless,  it  should  be  carefully  watched. 

Like  all  other  operations,  whether  bloody  or  bloodless,  upon  the  uterus, 
antisepsis  should  be  observed,  with  the  exception  of  the  spray. 

The  results  of  incision  of  the  cervix,  when  practised  in  suitable  cases, 
are  sometimes  very  gratifying.  In  cases,  however,  in  which  the  cervical 
tissue  has  undergone  atrophy,  or  become  hard  and  contracted,  it  is  often 
impossible  to  keep  the  canal  pervious.  It  gradually  contracts  in  spite  of 
all  that  can  be  done  to  oppose  its  doing  so. 

Treatment  of  Cases  Dependent  upon  Flexion  or  Version.— Should  ver- 
sion be  the  cause  of  dysmenorrhoea,  it  should  be  relieved  not  by  operation, 
but  by  the  means  already  mentioned  when  speaking  of  that  displacement. 
If  the  difficulty  be  due  to  flexion,  and  more  particularly  to  anteflexion, 
two  indications  offer  themselves  for  its  relief:  1st,  to  straighten  the  bent 
canal  by  keeping  the  body  of  the  uterus  erect ;  2d,  to  effect  the  same  end 
by  surgical  operation. 

If  a  uterus  be  flexed  below  the  vaginal  junction,  it  is  evident  that  ob- 
struction to  the  menstrual  flow  will  occur  at  the  point  of  flexure,  and 
equally  evident  that  an  incision  through  both  sides  of  the  canal  would  not 
overcome  this  by  straightening  it,  while  a  single  incision  through  the  pos- 
terior wall  would  do  so.     In  1862  Dr.  Sims  conceived  and  practised  such 


G20  DYSMENORRHEA. 

an  operation  successfully.  This  will  be  found  described  in  the  chapter  on 
flexion.  It  is  unquestionably  the  procedure  most  applicable  to  the  relief 
of  dysmenorrhea  due  to  anteflexion. 

Treatment  of  Vaginal  Stricture. — This  condition,  which  may  be  con- 
genital, or  be  induced  by  syphilitic  or  cancerous  disease,  or  by  sloughing, 
if  so  complete  as  entirely  to  obstruct  the  canal,  produces  amenorrhcea.  If 
it  be  a  pervious  stricture,  it  may  result  in  dysmenorrhea. 

The  affection  may  be  treated  by  three  methods :  dilatation  by  large 
bougies,  dilatation  by  tents,  and  incision.  If  syphilis  be  ascertained  to  be 
the  basis  of  the  local  disorder,  constitutional  means  should  at  the  same 
time  be  resorted  to. 

Treatment  of  Dysmenorrhea  from  Polypus Should  the  presence  of  a 

small  polypus  be  discovered,  the  cervix  should  be  dilated  by  tents  and  the 
growth  removed. 

Treatment  of  Obturator  Hymen  and  Fibroids. — The  first  should  be  in- 
cised with  extreme  caution,  and  the  second  removed,  if  possible,  by  one 
of  the  methods  mentioned  under  the  head  of  fibroids. 

Membranous  Dysmenorrhea. 

Definition This  variety  of  dysmenorrhcea  consists  in  the  expulsion  of 

organized  material  from  the  uterine  cavity,  at  menstrual  periods,  which  is 
found  upon  microscopical  examination  to  consist  of  the  lining  membrane 
of  the  uterus  itself.  This  may  consist  of  a  sac,  representing  the  triangular 
cavity  of  the  body  of  the  uterus  with  its  three  openings,  or  it  may  come 
away  piecemeal  as  shreds  or  strips  of  mucous  membrane. 

Observers,  since  the  time  of  Morgagni,  have  recognized  this  form  of 
disordered  menstruation,  but  looked  upon  the  mould  cast  off  as  formed  of 
false  membrane,  and  as  being  a  result  of  croupy  or  diphtheritic  endome- 
tritis. For  the  true  explanation  of  the  phenomenon  we  are  indebted  to 
Simpson,  Oldham,  and  Virchow. 

Pathology. — Dr.  Oldham's  opinion,  which  strikes  me  as  the  most  rational, 
not  only  upon  theoretical  grounds,  but  from  close  observation  of  those  cases 
which  have  come  under  my  notice,  is  that  at  some  time  during  the  inter- 
menstrual period,  the  entire  lining  membrane  of  the  uterus  is  lifted  from 
its  base  and  separated,  so  as  to  be  ready  for  extrusion  at  one  of  the  next 
menstrual  crises.  Virchow  declares  that  a  deciduous  membrane,  similar 
to  that  of  pregnancy,  forms,  and  for  this  membrane  he  proposes  the  name 
of  the  "  menstrual  decidua."  Dr.  Oldham  believed  that  congestion  of  the 
ovaries  gave  rise  to  this  remarkable  phenomenon,  by  transmitting  an  irri- 
tant influence  to  the  uterus.  However  inaugurated,  this  process  appears 
to  prepare  the  membrane  gradually  for  complete  detachment  and  extrusion 
at  a  menstrual  period,  when  it  is  expelled.  Simpson,  denying  the  causa- 
tive influence  of  inflammation  in  the  production  of  the  menstrual  decidua, 


MEMBRANOUS  DYSMENORRHEA.  621 

regards  it  as  a  product  natural  to  the  uterus  as  to  function,  but  unnatural 
as  to  time,  circumstances,  and  frequency  of  development. 

An  entire  membranous  cast,  when  washed  and  examined  by  the  naked 
eye,  is  found  to  be  triangular,  with  three  openings,  two  at  its  upper  angles 
and  one  at  its  lower.  Its  external  face  is  soft  and  irregular,  and  every- 
where shows  small  perforations,  which  are  openings  of  utricular  follicles. 
The  inner  face  is  free  from  inequalities,  and  feels  like  mucous  membrane. 
These  sacs  are  usually  extruded  as  they  lie  in  utero,  but  sometimes  they 
are  inverted.  In  one  instance  I  have  known  such  a  sac  to  become  in- 
verted and  expelled  into  the  vagina,  but  the  cervical  extremity  holding  its 
attachment  at  the  os  internum,  the  inverted  bag  hung  like  a  polypus  in 
the  vagina.     A  similar  case  is  recorded  by  Mme.  Boivin. 

Under  the  microscope  the  cast  is  found  to  consist  of  the  lining  membrane 
of  the  uterus,  hypertrophied  in  all  its  elements  almost  exactly  as  it  is  in 
pregnancy.  Indeed,  as  I  shall  soon  show,  the  most  skilful  microscopist 
cannot  distinguish  one  from  the  other.  The  vessels  of  the  mucous  mem- 
brane are  increased  in  size,  capacity,  and  number,  a  proliferation  has 
taken  place  in  its  epithelial  cells,  and  great  development  has  occurred  in 
the  utricular  glands,  the  mouths  of  which  are  visible  even  to  the  naked 
eye. 

Etiology. — This  part  of  our  subject  constitutes  one  of  its  most  important 
and  interesting  points,  but,  unfortunately,  that  diversity  of  opinion  which 
always  characterizes  unsettled  questions  is  found  to  exist  here.  Our  want 
of  accurate  information  depends  upon  the  fact  that  the  true  pathology  of 
the  condition  is  not  known.  Some,  with  Oldham  and  Tilt,  regard  it  as  a 
result  of  ovarian  disease ;  others,  with  Raciborski,  Lebert,  Handheld 
Jones,  and  Simpson,  look  upon  it  as  a  pure  desquamation  or  exfoliation  of 
the  uterine  mucous  membrane  for  which  no  cause  can  be  assigned  ;  while 
Klob  and  others  are  convinced  that  it  is  an  exudation,  the  result  of  endo- 
metritis, thus  returning  to  the  position  assumed  by  our  forefathers.  In 
further  reference  to  etiology  I  shall  give  a  resume  of  the  views  which  have 
been  and  are  received,  and  mention  some  of  the  authorities  who  adhere  to 
them. 

1.  It  was  formerly  believed  that  a  layer  of  plastic  lymph  was,  as  a 
result  of  endometritis,  thrown  out  over  the  uterine  wall,  which,  becoming 
organized,  constituted  the  cast  of  the  uterus.  This  belief  was  entertained 
by  Montgomery,  Dewees,  Siebold,  Frank,  Kaegele,  Desormeaux,  and 
others. 

2.  It  is  now  regarded  as  an  exfoliation  of  the  entire  mucous  membrane 
of  the  uterine  body,  due  to  congestion  and  irritation  transmitted  to  the 
uterus.  This  view,  conceived  by  Oldham,  is  adhered  to  by  Semelaigne 
and  others. 

3.  The  pathological  explanation  just,  mentioned  being  adopted,  the 
cause  of  the  occurrence  of  the  exfoliation  is  attributed,  in  the  words  of 


622  DYSMENORRHEA. 

Scanzoni,1  to  "  a  considerable  hyperemia  of  the  walls  of  the  uterus,  which 
is  followed  by  an  excess  in  the  development  of  the  mucous  membrane." 
This  theory  is  adopted  by  Courty,  Hegar,  Eigenbrodt,  and  others.  The 
last  two  authorities  have  proposed  for  it  the  name  of  "  dysmenorrhea 
apoplectica."2 

4.  Prof.  Simpson*  attributed  the  exfoliation  "to  an  exaggeration  of  a 
normal  condition,  or  to  an  exalted  degree  of  a  physiological  action." 
Mandl  declares  that  Rokitansky,  Robin,  Mayer,  and  others  adopt  this 
view.  He  further  attributes  the  same  belief  to  Klob,  Courty,  and  Braun, 
but  in  this  I  think  that  he  is  in  error. 

5.  It  is  regarded  as  due  to  an  inflammatory  condition  by  Klob,4  who 
declares  that  "those  pathologists  were  not  far  from  the  truth  who  described 
such  cases  as  endometritis."  This  view  is  indorsed  by  Tilt,8  Braun,6  and 
others. 

6.  By  some  the  membrane  is  regarded  as  due  to  a  deciduous  formation 
excited  by  conception  which  has  just  been  established,  or  is  ovular  in  its 
character.  The  first  of  these  views  is  maintained  by  Hausman,7  and  ad- 
mitted in  some  cases  by  Rokitansky  ;8  and  the  second  was  advanced  by 
Raciborski. 

From  my  observation  of  this  affection,  I  cannot  attribute  it  to  endo- 
metritis, for  evidence  of  the  existence  of  that  disease  was  entirely  wanting 
in  four  cases  out  of  five.  Even  if  endometritis  exist  with  marked  dis- 
placement, it  must  not  be  concluded  that  these  conditions  have  necessarily 
produced  exfoliation,  for  they  are  commonly  present  as  results  in  cases  in 
which  dysmenorrhcea  of  membranous  type  has  lasted  long  without  evidence 
of  their  existence. 

Frequency I  cannot  regard  the  disease  as  one  of  frequent  occurrence, 

for  in  my  experience  I  have  met  with  it  but  five  times.  It  is  true  that  I 
have  seen  a  number  of  cases  which  had  been  regarded  as  of  this  character, 
but  most  of  them  proved  not  to  be  so  upon  closer  examination.  Scanzoni 
reports  twenty-one  cases. 

Differentiation The  diseases  with  which  this  may  be  confounded  are — 

Early  abortions ; 

Blood  casts,  or  fibrinous  moulds  of  the  uterus ; 

Exfoliation  of  the  vaginal  mucous  membrane ; 

Diphtheritic  endometritis. 

»  Op.  cit.,  p.  348. 

2  For  my  citation  of  authorities  on  this  subject,  especially  those  of  Germany,  I 
rely  upon  a  very  valuable  article  by  Dr.  Mandl,  of  Vienna,  translated  in  the  N.  Y. 
Obstet.  Journ.,  vol.  ii.  p.  402.     To  this  essay  I  am  much  indebted. 

8  Clin.  Lect.  on  Dis.  of  Women,  Am.  ed.,  p.  109. 

*  Op.  cit.,  p.  237.  6  Lancet,  1853. 

6  Expression  of  opinion  in  Dr.  Mandl's  case.     See  his  article,  p.  413. 

^  Mandl's  article,  p.  407.  8  Klob,  op.  cit.,  p.  237. 


MEMBRANOUS  DYSMENORRHEA.  623 

From  the  first  of  these  the  differentiation  can  be  accomplished  by  the 
progress  of  the  case,  the  repetition  of  the  process,  and  the  entire  absence 
of  the  symptoms  of  pregnancy.  The  great  difficulty  which  attends  deter- 
mination of  the  character  of  one  specimen  may  be  gathered  from  two 
quotations  from  Dr.  Mandl's  article,  already  often  alluded  to.  They  are 
from  reports  by  "Wedl  and  Rokitansky,  who  exposed  specimens  from  the 
same  patient  to  the  microscope.  "Wedl's1  report  ends  in  these  words :  "  This 
proves  that  the  membranes  belong  to  the  decidua  and  chorion,  and  are 
parts  of  an  ovum  of  the  first  weeks  of  pregnancy."  Rokitansky's2  report 
contains  this  passage:  "The  development  of  the  mucous  membrane  is  in 
excess  of  its  usual  menstrual  degree.  It  is  not,  however,  connected  with 
conception." 

Blood  casts  will  readily  be  recognized  by  the  microscope.  No  elements 
of  uterine  mucous  membrane  are  discovered. 

The  microscope,  too,  will  readily  show  the  nature  of  false  membranous 
casts  of  the  uterine  body,  and  of  exfoliations  of  the  vagina  due  to  what 
Dr.  Tyler  Smith  has  styled  epithelial  vaginitis,  or  to  contact  with  per- 
chloride  or  persulphate  of  iron. 

Symptoms With  the  consmencement  of  the  menstrual  flow  there  are 

steady  pains,  which  increase  as  this  progresses  until  they  become  violent 
and  expulsive  like  those  of  abortion.  In  a  patient  whom  I  have  ?een 
with  Dr.  "VValser,  of  Staten  Island,  they  are  so  excessive  that  she  cannot 
find  words  to  express  her  dread  of  their  recurrence.  Under  these  the  os 
gradually  dilates,  and  the  membrane  is  forced  out  into  the  vagina.  Then 
there  is  commonly  a  tendency  to  menorrhagia,  which,  however,  soon  dis- 
appears, and  the  patient  has  passed  through  the  attack.  For  some  time 
after  it  has  passed  off  there  are  symptoms  of  endometritis,  and  purulent 
and  sanguineo-purulent  discharges.  Sometimes,  according  to  Iluchard 
and  Labadie-Lagrave,  who  have  written  an  excellent  article  upon  this 
subject  in  the  Archives  Generales  for  July,  1870,  membranous  dysmenor- 
rhea becomes  complicated  by  diphtheritic  endometritis,  which  is  en- 
grafted upon  an  attack  of  endometritis  set  up  by  the  affection  which  we 
are  considering. 

Pain  occurring  with  the  commencement  of  menstruation  ends  only  with 
the  discharge  of  the  exfoliated  membrane.  This  membrane,  as  has  been 
already  mentioned,  is  pathognomonic  of  the  kind  of  dysmenorrhoea  which 
exists,  and  serves  to  differentiate  it  cleai'ly  from  all  other  varieties.  The 
appearance  of  the  membrane  is  represented  in  Fig.  244. 

Proynosis. — The  prognosis  as  to  cure  is  extremely  unfavorable,  although 
cases,  not  only  of  complete  cure,  but  instances  in  which  in  advanced 
stages  of  the  disease  conception  has  occurred,  have  been  reported  by  Sie- 

1  Mandl,  loc.  cit.,  p.  415.  !  Mandl,  loc.  cit.,  p.  416. 


624  DYSMENORRHEA. 

bold,1  Tyler  Smith,  D'Outrepont,  and  others.    Two  such  cases  have  come 
under  my  own  observation. 

Fio.  244. 


Dysmenorrhoeal  membrane.     (Coste.) 

Treatment "When  the  etiology  and  pathogenesis  of  a  disease  are  un- 
known, it  is  astonishing  to  see  how  various,  contradictory  and  energetic, 
treatment  usually  is.  Deficiency  of  knowledge  in  these  respects  rarely 
results  in  an  expectant  plan  of  treatment.  It  commonly  induces  excessive 
vigor  of  interference.  In  the  disease  which  we  are  now  considering,  the 
actual  cautery  has  been  freely  applied  to  the  cervix,  while  solid  nitrate  of 
silver  and  other  caustics  have  been  carried  up  to  the  fundus. 

Uncertain  as  we  are  as  to  the  pathology  of  the  disorder,  little  can  be 
said  with  any  positiveness  as  to  treatment.  For  relief  of  the  violent  pains 
which  attend  the  attack,  nothing  compares  in  quickness,  certainty,  and 
efficiency,  with  the  injection  of  morphia  by  the  hypodermic  syringe.  If 
this  use  of  the  drug  be  not  inadmissible  on  account  of  constitutional  in- 
tolerance, it  should  be  resorted  to  once  in  every  eight  or  every  twelve 
hours.  Should  there  be  any  objection  to  its  use,  the  pains  of  the  attack 
should  be  quieted  by  inhalations  of  sulphuric  ether  carried  only  to  the 
point  of  producing  quiescence  of  the  nervous  system,  not  sleep  or  uncon- 
sciousness. 

If  uterine  or  ovarian  disease  be  detected,  it  should  be  treated  in  accord- 
ance with  general  rules.  If  no  such  cause  for  the  exfoliation  be  discovered 
applications  of  alterative  character  may  be  made  to  the  uterine  mucous 
membrane,  as  tincture  of  iodine,  chromic  or  carbolic  acid,  solution  of 
nitrate  of  silver,  or  solution  of  persulphate  of  iron.     Dr.  Fordyce  Barker 

•  Mandl,  loc.  cit.,  p.  423. 


OVARIAN    DYSMENORRHEA.  625 

reports  very  satisfactory  results  from  passing  into  the  cavity  of  the  body 
an  ointment  containing  from  one  to  three  grains  of  iodoform,  to  the  amount 
introduced.  Should  displacement  exist,  it  should  be  relieved,  upon  the 
principle  that  if  we  cannot  cure  a  disorder,  it  is.  at  least  wise  to  relieve 
its  most  prominent  complications  and  disagreeable  symptoms.  The  mea- 
greness  of  this  advice  as  to  the  treatment  of  so  distressing  a  malady  is 
but  too  apparent,  but  there  is  no  help  for  it,  as  it  arises  from  an  absolute 
want  of  knowledge  as  to  more  certain  therapeutic  resources. 

Ovarian  Dysmenorrhea. 

Definition — In  a  number  of  cases,  unfortunately  by  no  means  small, 
no  depreciated  condition  of  the  nervous  system  will  be  found  to  account 
for  habitual  dysmenorrhea ;  and  the  most  careful  exploration  of  the  pelvis 
will  fail  to  discover  uterine  or  periuterine  disorder.  In  such  cases,  if  by 
conjoined  manipulation  the  regions  to  the  side  of  and  behind  the  uterus  be 
investigated,  a  globular,  slightly  compressed  mass,  about  the  size  of  a  large 
walnut  or  small  egg,  will  often  be  found  in  the  cul-de-sac  of  Douglas,  or 
on  one  or  both  sides  of  the  uterus,  low  down,  and  in  close  proximity  to  it. 
If  the  patient  be  now  placed  in  the  left  lateral  position,  and  two  fingers  of 
the  right  hand  be  carried  up  the  vagina,  their  palmar  surfaces  looking 
backwards,  the  presence  of  these  smooth  and  movable  bodies  will  be  still 
better  ascertained.  They  are  the  ovaries,  enlarged,  congested,  tender, 
and  prolapsed. 

In  some  cases  their  disordered  condition  will  be  accompanied  merely 
by  dysmenorrhea ;  but  in  others  it  will  be  marked  by  hysteria,  amenor- 
rhea alternating  with  monorrhagia,  and  even  by  true  epilepsy.  Whether 
epilepsy  is  in  such  cases  due  to  the  existing  ovarian  disease,  I  am  un- 
prepared to  state;  but  I  have  so  often  seen  it  accompany  it  that  I  freely 
confess  my  belief  that  it  is  sometimes  caused  by  it.  This  is  the  condition 
commonly  styled  chronic  ovaritis ;  which  consists  in  congestion  as  its  first 
stage,  and  hyperplasia  of  tissue  with  excessive  nervous  hyperesthesia  as 
its  second.  In  several  of  these  cases,  where  I  have  had  an  opportunity  of 
examining  the  ovaries,  I  have  found  them  filled  with  numerous  small  cysts. 

Symptotns It  would  be  difficult  to  make  the  diagnosis  of  this  form  of 

painful  menstruation  by  rational  signs  alone.  It  should  rest  upon  a  union 
of  rational  and  physical  signs  ;  but  a  suspicion  as  to  the  nature  of  the 
case  would  generally  be  formed  from  the  former.  The  pain  precedes  the 
bloody  flow  by  several  days,  and  diminishes  as  it  is  established.  It  is  of 
a  dull  character,  extends  down  the  thighs,  is  peculiarly  likely  to  be  accom- 
panied by  nervous  manifestations,  and  to  create  depression  of  spirits.  The 
breasts  often  sympathize,  becoming  painful  and  tender  to  the  touch. 

One  very  curious  phenomenon  which  now  and  then  marks  these  cases 
is  the  occurrence  of  intermenstrual,  or  "  intermediate  pain,"  as  it  has  been 
styled  by  Dr.  Priestley.  At  times  this  occurs  with  wonderful  regularity 
40 


626  DYSMENORRHEA. 

on  a  given  day.  In  one  case  in  my  experience  it  occurred  on  the  ninth 
day  after  menstruation  had  ceased ;  in  another  on  the  fourteenth ;  and  in 
a  third  it  commenced  one  week  after  the  menstrual  act,  and  continued  for 
five  or  six  days. 

It  must  not  be  supposed  that  in  every  case  in  which  the  ovaries  are 
discovered  to  be  large,  tender,  and  prolapsed,  dysmenorrhea  will  neces- 
sarily exist ;  nor  that  they  will  always  be  found  in  this  condition  where 
there  are  other  reasons  for  suspecting  ovarian  dysmenorrhea.  The  rule 
is  as  I  have  stated,  but  it  is  by  no  means  without  exceptions. 

Pathology. — It  is  possible  that  the  process  of  ovulation  in  a  diseased 
ovary  may  excite,  through  its  extensive  and  decided  nervous  connections, 
congestion  and  nervous  hyperesthesia  in  the  uterus,  which  would  create 
disordered  menstruation  of  the  congestive  or  neuralgic  type.  Ordinarily, 
however,  the  pain  seems  to  be  in  the  diseased  ovaries  themselves,  and  to 
depend  upon  the  dehiscence  of  the  follicles  of  De  Graaf.  This  can  be 
proven  by  touching  these  organs  during  the  early  periods  of  menstruation, 
and  is  made  evident  in  cases  in  which  ovulation  occurs  without  menstrua- 
tion, in  cases  of  atresia  or  absence  of  the  uterus. 

Prognosis — The  prognosis  of  dysmenorrhea  due  to  this  cause  is  very 
bad.  In  a  young  girl  in  whom  ovarian  disorder  has  advanced  only  to 
congestion,  recovery  may  rapidly  take  place ;  but  in  a  woman  further  ad- 
vanced in  life,  and  in  whom  chronic  enlargement  of  the  ovaries  has 
occurred,  and  become  associated  with  great  tenderness  and  prolapse,  the 
prospects  of  cure  are  very  unpromising. 

Treatment. — In  such  cases  sterility  is,  I  think,  the  rule.  If  utero- 
gestation  should  be  inaugurated,  the  nine  months  of  inactivity  and  repose 
secured  by  it  to  the  ovaries,  is  likely  to  be  of  great  service.  I  have  yet  to 
meet  with  a  case  of  chronic  character  in  which  I  have  effected  a  cure  by 
purely  medicinal  means.  By  anodynes  and  nervines,  of  course  pain  may 
be  annihilated,  but  this  is  far  from  effecting  cure,  and  their  use  possesses 
the  additional  disadvantage  of  exposing  the  patient  to  the  dangers  of  con- 
tracting a  bad  habit  in  reference  to  their  future  employment. 

All  means  calculated  to  soothe  local  irritation,  to  give  tone  to  the  ner- 
vous system,  and  to  combat  sanguineous  excitement,  should  be  resorted 
to.  Change  of  air  and  scene,  a  visit  to  the  mineral  springs  and  baths  of 
Germany  and  France,  and  removal  of  all  influences  which  severely  or 
disagreeably  tax  either  mind  or  body,  will  often  accomplish  great  good. 
"Warm  sitz  baths  and  warm  and  soothing  vaginal  injections  should  be  em- 
ployed, and  complete  rest  in  bed,  or  great  cpjietude  if  the  patient  objects 
to  bed,  should  be  prescribed  during  menstrual  periods  and  for  three  or  four 
days  after  them.  Internally  I  know  of  no  means  which  are  so  efficacious 
as  the  free  use  of  the  bromides  of  potassium  and  ammonium,  commenced 
a  week  before  the  menstrual  act  and  continued  until  its  close. 

During    menstruation,  opiates,  alcoholic    stimulants,   and   anesthetics 


OVARIAN    DYSMENORRHEA.  627 

should,  as  far  as  possible,  be  avoided.  Their  use  will  probably  give  relief, 
and  as  a  consequence  they  will  be  resorted  to  once  a  month  thereafter. 
The  danger  of  such  a  course  is  apparent.  In  place  of  them  the  tincture 
of  cannabis  Indica,  hyoscyamus,  and  camphor,  or  five  grain  doses  of  the 
monobromate  of  camphor,  may  be  employed.  In  some  cases  I  have 
known  a  rectal  suppository  of  five  grains  of  iodoform  give  great  relief. 

I  am  unwilling  to  convey  the  idea  that  even  these  means  are  prolific  of 
good  results  in  such  cases.  They  are  by  no  means  so,  and  are  merely 
offered  as  the  best  with  which  I  am  acquainted.  My  own  experience 
leads  me  to  dread  the  application  for  relief  of  one  of  these  obstinate  and 
unsatisfactory  cases. 

Before  leaving  this  subject  I  must  put  the  reader  upon  his  guard  in 
reference  to  the  following  point.  In  treating  of  the  subject  of  dysmenor- 
rhoca  I  have  accepted  all  the  varieties  which  are  generally  indicated  by 
authorities,  because  I  believe  that  by  their  adoption  a  more  thorough  inves- 
tigation of  the  subject  is  secured,  and  because  experience  leads  me  to 
think  that  a  recollection  of  them  at  the  bedside  will  aid  the  practitioner 
in  classification  and  treatment.  It  must  not,  however,  be  supposed  that 
every  case  of  dysmenorrhea  will  prove  susceptible  of  strict  limitation  to 
one  of  these  varieties.  Such  an  anticipation  will  lead  to  disappointment 
and  distrust  of  this  classification.  Many,  indeed  most,  cases  demonstrate 
the  existence  of  more  than  one  disturbing  element.  Thus,  for  example, 
retroversion  occurring  in  a  debilitated,  weak,  and  nervous  woman,  whose 
blood  is  impoverished,  might  cause  a  dysmenorrhea,  due  in  part  to  me- 
chanical obstruction,  in  part  to  neuralgia,  in  part  to  congestion,  and  per- 
haps even  to  a  certain  extent  to  a  secondary  endometritis.  Too  much 
must  not  be  expected  from  any  classification,  and  it  must  be  borne  in 
mind  that  one  of  the  great  ends  in  view,  in  adopting  this  style  of  arrange- 
ment, is  the  attainment  of  thoroughness  of  investigation  and  facility  of 
remembrance. 

In  view  of  the  fact  which  I  have  just  mentioned,  it  is  well  for  the  prac- 
titioner to  have  at  his  disposal  some  gerueral  plan  of  treatment  which  may 
be  resorted  to  in  cases  not  readily  susceptible  of  classification.  The  fol- 
lowing is  one  which  I  think  will  be  found  effectual.  As  soon  as  menstru- 
ation begins,  or  some  hours  before  if  its  approach  can  be  recognized,  the 
patient  should  go  to  bed  and  apply  warmth,  by  bottles  of  warm  water, 
warm  bricks  wrapped  in  dry  flannel,  or,  as  is  better,  by  bags  of  India- 
rubber  filled  with  warm  water,  to  the  feet,  abdomen,  and  sacrum  alter- 
nately. She  should  then  take  by  the  rectum  an  enema  composed  as 
follows  : — 

R;. — Tr.  assafoetidce,  31J.  * 

Tr.  belladonna;,  gtt.  xx. 

Tr.  opii,  gtt.  x. 

Aquae  tepidae,  §iijss. — M. 
S. — Throw  the  whole  into  the  rectum  and  retain. 


628  MENORRHAGIA    AND    METRORRHAGIA. 

If  the  patient  have  any  decided  objection  to  the  use  of  an  enema,  the 
following  prescription  will  be  found  very  useful : — 

R. — Chloral,  hydrat.  3ij. 
Potassii  bromidi,  3'j« 
Morphiae  sulphat.  gr.  iss. 
Syrupi  aurantii  cort.  .^iij. — M. 
S. — A  dessertspoonful  in  a  wineglassful  of  sweetened  water  every  four  hours 
while  in  pain. 

The  following  suppository  will  sometimes  prove  useful  in  place  of  the 

enema : — 

R. — Belladonnas  ext.  gr.  j. 
Opii  pulv.  gr.  iij. 
Assafoetidae  gum.  5ss. 
Butyr.  cacao,  q.  s. 
M.  et  ft.  supposit.  No.  vi. 
S. — One  by  the  bowel  night  and  morning  while  suffering. 

I  must  again  reiterate  that  one  great  care  of  the  physician  in  these  cases 
should  be  to  avoid  creating  in  the  patient  a  craving  for  opiates  and  stimu- 
lants. Barnes  writes  upon  this  so  ably  and  justly,  that  I  cannot  refrain 
from  referring  the  reader  to  his  excellent  work. 


CHAPTER   XLI. 

MENORRHAGIA  AND  METRORRHAGIA. 

Definition. — The  first  of  these  terms  is  employed  for  the  designation  of 
a  profuse  and  excessive  flow  of  blood  at  the  menstrual  periods;  the  second 
for  any  flow  of  blood,  whether  profuse  or  not,  during  the  intervals.  A 
patient  who  menstruates  too  profusely  is  said  to  suffer  from  menorrhagia, 
while  one  who  loses  blood  not  only  at  menstrual  periods  but  in  the  inter- 
vals is  said  to  suffer  from  metrorrhagia. 

Frequency. — Both  of  these  conditions  are  necessarily  frequent,  for  they 
are  both  symptomatic  of  a  large  number  of  both  functional  and  organic 
affections  of  the  uterus.  The  uterus  is  the  only  organ  in  the  body  from 
which  blood  flows  as  a  physiological  process.  Many  organs  and  all  the 
erectile  tissues  are  subject  to  normal  congestions,  but  from  none  except 
the  uterus  is  a  flow  of  blood  ever  other  than  a  morbid  process.  It  is  not 
then  astonishing  than  in  this  organ  slight  and  numerous  causes  are  apt  to 
excite  hemorrhage. 

Pathology. — 1st,  any  condition  which  induces  a  state  of  active  or  passive 
congestion  of  the  uterine  parenchyma  or  lining  membrane  ;  2d,  any  influ- 
ence creating  a  solution  of  continuity  upon  its  mucous  surface ;  3d,  any 


causes.  629 

growth  which,  having  a  vascular  connection  with  the  uterine  vessels,  al- 
lows of  a  percolation  through  its  tissues  and  from  its  circumference ;  and 
4th,  any  agency  producing  dyscrasia  of  the  hlood  may  result  in  these  dis- 
orders. Any  one  of  these  conditions  existing  alone  may  produce  the  flow  ; 
several  comhined  are  still  more  certain  to  do  so.  It  must,  however,  be 
admitted,  that  very  violent  hemorrhages  will  sometimes  take  place  from 
the  non-pregnant  uterus  without  our  being  able  to  determine  their  cause, 
none  of  the  conditions  just  mentioned  being  recognizable. 

Catises The  conditions  which  most  frequently  occasion  menorrhagia 

and  metrorrhagia  are — 

General  plethora ; 

Areolar  hyperplasia ; 

Polypus  ; 

Fecal  impaction ; 

Granular  degeneration ; 

Fibrous  tumors  ; 

Chronic  ovaritis  ; 

Cancer  or  sarcoma ; 

Retained  products  of  conception  ; 

Fungous  degeneration  of  uterine  mucous  membrane  ; 

Hematocele  ; 

Subinvolution  ; 

Any  displacement  of  the  uterus. 
Congestion  of  the  uterus  is  very  common  at  the  period  of  the  menopause, 
or  as  a  result  of  violent  muscular  efforts.     It  may  likewise  occur  as  a 
consequence  of  abortion,  an  impeded  hepatic  circulation,   endometritis, 
areolar  hyperplasia,  displacements,  chronic  ovaritis,  or  fecal  impaction. 

Retention  of  some  of  the  products  of  conception  is  very  frequently  a 
cause.  The  placenta  may  remain  in  part  or  in  whole,  the  foetal  shetl  may 
become  a  mole,  or  the  chorion  may  undergo  degeneration,  and  uterine 
hydatids,  as  they  are  erroneously  called,  collect  within  the  uterus. 

Simple  hyperplasia  of  the  lining  membrane  of  the  uterus,  styled  vege- 
tation or  fungous  degeneration,  is  the  most  frequent  source  of  both  vari- 
eties of  hemorrhage.  The  vegetations  thus  created  were  described  by 
Recamier,  who  advised  and  practised  scraping  them  off  by  means  of  a 
steel  instrument.  M.  Aran,  who  has  written  an  excellent  article  upon 
them  in  his  work  on  the  Diseases  of  the  Uterus,  thus  describes  them. 
"  They  present  themselves  in  two  entirely  different  forms.  In  the  first 
and  most  common  form  they  are  tumors,  ordinarily  sessile,  continuous 
with  the  mucous  membrane  by  a  base  sometimes  as  large  as  themselves. 
They  vary  in  size  from  that  of  a  grain  of  wheat  or  a  little  pea  to  that  of  a 
large  pea  and  even  of  a  small  strawberry  or  a  large  raspberry.  The  last 
are  often  pediculated."  These  are  styled  cellulo-vascular  vegetations,  and 
may  exist  in  any  part  of  the  cavity  of  the  uterus.     Generally  they  do  not 


630  MENORRHAGIA    AND    METRORRHAGIA. 

exceed  two  or  three  in  number,  and  are  found  in  the  cavity  of  the  body. 
"  In  the  second  form  they  are  a  species  of  pediculated  vegetations  resem- 
bling in  appearance  those  follicular  polypi  which  are  so  common  in  the 
neck  of  the  uterus.  They  vary  in  size  from  that  of  a  grain  of  wheat  to 
that  of  a  pea."  These  are  called  cellulo-fibrous  vegetations.  Both  vari- 
eties generally  result  from  chronic  engorgement  of  the  mucous  lining  of 
the  uterus.  As  a  consequence  of  subinvolution  they  are  very  frequently 
met  with,  and  markedly  complicate  that  condition. 

Sometimes  after  an  abortion,  at  other  times  after  labor  at  full  term, 
hemorrhage  will  steadily  continue  without  any  assignable  cause.  If  the 
cervical  canal  be  dilated,  little  fungoid  growths  will  be  found  attached  to 
a  circumscribed  portion  of  the  uterine  wall,  which  being  removed  by  the 
curette,  the  flow  will  at  once  cease.  This  variety  of  fungoid  growths  fol- 
lows so  closely  upon  the  parturient  act,  that  it  appears  probable  that  they 
arise  from  minute  portions  of  placenta,  which,  remaining  attached,  draw 
their  nourishment  from  the  uterine  vessels.  I  have  no  positive  evidence 
of  the  truth  of  this  view,  for,  although  I  have  often  had  these  growths 
microscopically  examined,  I  have  not  obtained  it  in  this  way.  Klob1 
mentions  a  peculiar  kind  of  flat  vascular  elevation  which  occurs  upon  the 
mucous  membrane  of  the  uterus  which  I  have  never  seen.  "  These  puffed 
elevations  are  red,  shiny,  velvety,  and  smooth  ;  on  scraping  them  with  a 
knife  a  milky  fluid  exudes  from  them,  which,  under  the  microscope, 
exhibits  nothing  but  the  glandular  epithelium  of  the  uterus,  sometimes 
transparent  vesicles  and  colloid  bodies  of  varying  size."  They  are  very 
vascular.  Klob  declares  that  in  the  case  of  a  woman  36  years  of  age 
death  occurred  from  metrorrhagia.  He  examined  the  uterus  post  mortem, 
and  "  was  unable  to  find  anything  except  such  a  vegetation  of  mucous 
membrane,  about  one  inch  thick  and  one  and  a  half  inches  in  diameter." 

It  is  astonishing  how  profuse  and  constant  a  flow  will  sometimes  result 
from  very  small  and  apparently  insignificant  vegetations.  Some  years 
ago  I  had  an  opportunity  of  examining  post  mortem  a  patient  of  Dr. 
Louis  Elsberg,  of  this  city,  of  whom  this  history  was  given.  The  patient 
had  suffered  for  years  from  menorrhagia  and  occasionally  from  metror- 
rhagia. On  many  occasions  Dr.  Elsberg  had  resorted  to  the  tampon,  and 
on  several  had  been  forced  to  plug  the  cervix  with  considerable  force  to 
prevent  death  from  the  excessive  flow.  Upon  inspection  I  found  nothing 
to  account  for  the  condition  but  three  fungous  projections,  which  were 
situated  just  above  the  os  internum.  They  resembled  somewhat  the 
warty  growths  sometimes  seen  upon  the  glans  penis,  except  that  their 
papillary  character  was  not  so  marked.  Unfortunately  they  were  de- 
stroyed before  they  could  be  examined  by  the  microscope.  It  may  be 
suggested  that  some  other  cause  might  have  existed,  but  none  such  was 

'  Op.  cit.,  p.  139. 


DIFFERENTIATION.  631 

discovered  upon  careful  investigation.  The  uterus,  ovaries,  and  pelvic 
tissues  appeared  to  be  in  a  perfectly  normal  condition. 

Chronic  ovaritis  often  results  in  great  menstrual  irregularity,  sometimes 
for  months  the  menstrual  discharge  does  not  occur,  and  then  without  any 
apparent  exciting  cause  a  dangerously  profuse  hemorrhage  occurs  which 
requires  the  most  energetic  means  to  control  it. 

My  experience  furnishes  me  with  a  number  of  cases  in  which  fecal  im- 
paction produced  prolonged  metrorrhagia,  which  was  cured  by  its  removal. 

Differentiation This  is  at  once  the  most  important  and  most  difficult 

of  the  physician's  duties  in  reference  to  the  symptoms  which  we  are  con- 
sidering. If  he  be  too  easily  persuaded  to  look  upon  the  loss  as  one  of 
the  results  of  the  "change  of  life,"  or  even  of  primary  idiopathic  conges- 
tion, much  time  may  be  lost  before  his  error  is  corrected.  Should  he 
forget  that  he  is  dealing  with  a  symptom,  and  look  upon  the  condition  as 
a  disease,  he  will  often  not  merely  lose  time,  but,  in  the  end,  entirely  fail 
in  giving  relief;  for  the  empirical  practice  of  confining  such  patients  to 
bed  and  relying  upon  astringents,  cold  applications,  and  narcotics,  will 
commonly  be  found  to  be  ineffectual.  In  every  case,  unless  the  cause  be 
palpable,  it  is  advisable  to  examine  systematically  the  entire  uterus  and 
its  surrounding  tissues  in  the  following  manner: — 

1st.  The  cervix  should  be  investigated  by  touch,  the  speculum,  and  the 
uterine  probe. 

2d.  The  anterior  and  posterior  walls,  and  the  fundus  and  sides  of  the 
uterus,  should  be  examined  by  conjoined  manipulation,  rectal  touch,  and 
palpation. 

3d.  The  whole  pelvis  should  be  explored  by  conjoined  manipulation, 
rectal  touch,  and  palpation. 

4th.  The  cervix  should  be  dilated  by  tents,  and  the  cavity  of  the  body 
explored  by  the  introduction  of  the  index  finger,  by  the  uterine  sound, 
and  the  curette. 

In  many  instances  a  diagnosis  can  be  made  only  by  these  means ;  but 
by  their  aid,  if  fully  developed,  very  few  cases  will  baffle  research. 

Tents  offer  us  a  most  valuable  means  for  diagnosis  and  treatment,  but 
the  practitioner  must  be  very  sure  to  open  the  os  internum  by  them  so 
that  the  finger  may  pass  to  the  fundus.  In  many  cases,  when  it  is  sup- 
posed that  a  full  investigation  of  the  uterine  cavity  has  been  made,  the  os 
internum  has  never  been  passed  by  the  finger,  which  consequently  ex- 
plores only  the  cervical  canal.  It  will  not  infrequently  require  three  and 
even  four  tents  to  open  the  cavity  of  the  body  fully  to  the  finger.  But 
such  an  exploration,  although  very  thorough  and  satisfactory,  is  not  free 
from  danger.  It  may,  therefore,  be  very  generally  replaced  by  the  passage 
of  a  loop  of  wire  over  the  endometrium.  If  any  small  tumor  exists,  it 
will  in  this  way  be  discovered,  and,  if  uterine  fungosities  exist,  the  re- 
moval of  one  or  more  will  very  surely  disclose  the  fact. 


632  MENORRHAGIA    AND    METRORRHAGIA. 

Prognosis This  will  depend  upon  the  cause  of  the  affection.     Should 

this  he  clearly  ascertainable  and  curable,  it  will,  of  course,  differ  very 
much  from  what  it  would  be  if  the  cause  were  obscure  and  difficult  of 
removal. 

Results Menorrhagia,  and,  more  markedly  still,  metrorrhagia,  if  un- 
checked, may  result  in — 

Sterility; 
Hydnemia; 
Hysteria ; 
Dyspepsia ; 
Extreme  emaciation ; 
Death. 

Treatment This  is  palliative  and  curative.  The  treatment  of  a  pro- 
fuse flow  of  blood  from  the  uterus,  as  from  any  other  part  of  the  body, 
should  always  consist  primarily  in  checking  it.  In  a  case  of  menorrhagia, 
the  patient  should  be  kept  perfectly  quiet  upon  her  back  ;  cloths  wrung 
out  of  cold  water  should  be  laid  over  the  uterus,  vulva,  and  thighs ;  cold, 
acidulated  drinks,  as  iced  lemonade,  solution  of  elixir  of  vitriol  in  ice- 
water,  etc.,  should  be  given  freely ;  and  the  ingestion  of  all  warm  fluids 
strictly  interdicted.  In  addition,  the  apartment  should  be  kept  cool,  the 
foot  of  the  bedstead  elevated  about  ten  inches,  the  nervous  system  quieted 
by  opium,  or  an  appropriate  substitute,  and  all  conversation  prohibited. 
Certain  general  hemostatics  should  always  be  tried  ;  among  the  chief  of 
which  are  gallic  acid,  ergot,  and  tincture  of  cannabis  indica.  The  last  is 
one  of  the  best  at  our  command. 

In  mild  cases  this  treatment  may  suffice,  but  in  severe  ones  it  will  not. 
In  these  the  speculum  should  be  introduced  and  the  vagina  filled  with  a 
tampon.  This  will  rarely  fail ;  but  in  certain  cases,  as,  for  instance,  those 
of  cancer  of  the  neck,  it  will  do  so.  Under  these  circumstances  the  tam- 
pon of  cotton  should  be  removed,  and  replaced  by  one  consisting  of  the 
same  material  saturated  with  a  strong  solution  of  alum,  or  with  the  officinal 
solution  of  persulphate  of  iron  diluted  with  four  times  its  bulk  of  water.  A 
stronger  solution  may  cause  sloughing  of  the  vaginal  mucous  membrane. 
A  solution  of  full  strength  has  been  known  to  produce  gangrene  of  the 
vaginal  walls  themselves.  Instead  of  using  these  solutions  a  small  linen 
bag  may  be  filled  with  powdered  alum,  placed  in  contact  with  the  cervix, 
and  held  in  place  by  a  tampon  ;  or  two  drachms  of  tannin  may  be  left  free 
against  the  part.  To  these  means  almost  all  cases  will  yield  temporarily, 
but  some  will  be  met  with  which  will  not  do  so,  and  in  which  even  more 
energetic  ones  are  called  for  to  prevent  death  from  loss  of  blood.  In  these 
exceptional  cases  the  cavity  of  the  body  of  the  uterus  should  be  freely  in- 
jected, after  dilatation  of  the  cervical  canal,  with  the  tincture  of  iodine, 
or  a  strong  solution  of  alum. 

Before  a  case  of  menorrhagia  is  subjected  to  this  course  of  management, 


CURATIVE    TREATMENT. 


633 


this  point  must  be  carefully  considered:  some  women  naturally  flow  very 
freely  at  menstrual  epochs,  and  are  not  injured  by  the  loss.  It  is  their 
peculiarity,  and  not  an  evidence  of  an  abnormal  state,  and  it  should  be 
decided  whether  or  not  treatment  be  required.  In  reference  to  metror- 
rhagia, it  is  equally  important  to  bear  in  mind  that  some  women,  during 
the  early  months  of  pregnancy,  have  a  steady  flow  of  blood,  and  before  a 
tent  is  employed,  or  probing  the  uterus  is  resorted  to,  this  state  should  be 
carefully  eliminated. 

Curative  Treatment One  great  reason  for  the  fact  that  this  often  proves 

fruitless  is  that  the  existing  disorder,  and  not  the  disease  which  produces 
it,  is  kept  before  the  mind  of  the  practitioner.  It  should  be  borne  in  mind 
that  the  excessive  hemorrhage  is  a  symptom,  and  that  the  morbid  state 
which  creates  it  must  be  sought  for  and  eradicated.  I  am  confident  that 
the  statement  already  made  that  one  of  four  great  pathological  factors  will 
usually  be  found  to  be  the  source  of  excessive  or  prolonged  uterine  hemor- 
rhage, will  stand  the  test  of  experience  at  the  bedside.  I  therefore  place 
before  the  reader  at  a  glance  the  ordinary  causes  of  uterine  congestion, 
solution  of  continuity,  growths  from  uterine  mucous  surface,  and  blood 
dyscrasia.  That  there  are  other  conditions,  such  as  pelvic  peritonitis, 
hematocele,  etc.,  which  may  cause  uterine  hemorrhage,  I  do  not  deny  5 
but  when  a  bloody  flow  marks  the  existence  of  such  grave  diseases,  it  is 
overshadowed  by  them  and  requires  no  special  treatment.  I  here  give 
those  which  ordinarily  produce  a  flow  which  requires  treatment  from  its 
prominence  and  importance,  although  I  am  almost  repeating  myself. 

Areolar  hyperplasia ; 

Subinvolution  ; 

Fibroids ; 
Congestion  of  uterine   tissue  may  be  j   General  plethora ; 


due  to 


Solution  of  continuity  may  be  created 


by 


Growths  from  uterine  walls  may  con- 
sist in 


Displacement ; 
Fecal  impaction ; 
Chronic  ovaritis ; 
Laceration  of  the  cervix. 
[  Ulceration  ; 
Granular  degeneration ; 
Cancer ; 
Sarcoma ; 

Laceration  of  the  cervix. 
Polypi ; 

Fungous  growths ; 
Adhering  products  of  concep- 
tion ; 
Fibroids ; 
Sarcoma  or  cancer. 


63-4  MENORRHAGIA  AND  METRORRHAGIA. 

Scorbutus ; 
Chlorosis ; 

Blood  dyscrasia  may  be  due  to  -^  Spansemia    from    uraemia   or 

other   grave   constitutional 
disease. 

If  the  source  of  the  disorder  be  discovered,  its  treatment  is  often  very 
simple  and  effectual,  and  as  the  management  of  most  of  the  conditions  here 
recorded  is  familiar  to  every  reader  upon  general  medicine,  or  is  given 
in  other  parts  of  this  work,  little  more  need  be  said  except  upon  one  or 
two  points. 

In  a  case  of  subinvolution,  the  free  use  of  ergot  will  be  found  a  valuable 
adjuvant  to  the  means  already  enumerated  for  palliative  treatment,  and  it 
may  prove  serviceable  as  a  curative  agent.  The  same  remark  applies  to 
the  fluid  extract  of  viscum  album,  which  maybe  well  employed  alternately 
with,  or  instead  of,  ergot.  In  the  treatment  of  all  uterine  congestions  the 
occasional  use  of  an  active  purgative,  or  the  systematic  and  steady  employ- 
ment of  the  same  class  of  medicines  in  small  doses,  will  often  prove  highly 
beneficial. 

Treatment  of  Fungous  Degeneration  of  the  Uterine  Mucous  Membrane. — 
If  this  condition  be  clearly  diagnosticated,  not  surmised,  but  fully  deter- 
mined upon  by  rational  and  physical  signs ;  the  first  consisting  in  pro- 
longed hemorrhage,  without  the  existence  of  other  disease  ;  and  the  second 
in  evidence  afforded  by  the  detachment  or  expulsion  of  some  of  these 
masses,  the  whole  lining  membrane  of  the  uterine  body  should  be  thor- 
oughly but  gently  scraped  by  the  curette  represented  in  Fig.  245. 


Fig.  245. 


G.T/EMAIMN  &.C0. 
Thomas's  wire  curette. 


^ 


Should  the  cervical  canal  be  narrow,  it  may  be  necessary  to  dilate  it  by 
a  sea-tangle  tent ;  but,  ordinarily,  no  previous  dilatation  is  necessary  for 
the  use  of  this  instrument,  which  should  be  passed  with  a  slight  degree  of 
scraping  action  over  the  entire  surface  of  the  uterine  body. 

In  recommending  the  curette  as  a  most  valuable  resource  in  the  treat- 
ment of  menorrhagia  due  to  fungous  degeneration  of  the  uterine  lining 
membrane,  I  do  so  from  very  extensive  and  constantly  increasing  expe- 
rience with  it.  I  employ  it  frequently  in  private  practice,  and  in  the 
"Woman's  Hospital  it  is  commonly  used  by  most  of  my  colleagues,  as  well 
as  by  myself.  Not  only  has  it  proved  in  my  hands  a  very  efficient  in- 
strument, but  one  attended  by  little  danger  unless  employed  in  cases 
previously  affected  by  peritonitis  or  cellulitis.  For  one  using  it  with  such 
results  it  is  difficult  to  comprehend  how  it  should  be  so  unfavorably  regarded 


AMENORRHEA.  635 

by  many  able  practitioners.  The  late  M.  Aran1  was  bitterly  opposed  to 
a  resort  to  it;  and  Gallard2  styles  its  use  a  "detestable  operation."  The 
latter  author  then  goes  on  to  speak  of  the  "perfect3  harmlessness  of  intra- 
uterine injections"  in  menorrhagia !  Truly,  experience  does  not  teach  to 
all  men  the  same  lessons,  though  all  may  sincerely  strive  to  read  its  teach- 
ings aright. 

In  place  of  the  curette  the  lining  membrane  of  the  uterine  body  may  be 
modified  by  the  application  of  pure  nitric  acid,  after  the  plan  of  Kidd  and 
Athill,  of  Dublin,  or  by  the  injection  of  the  uterine  cavity  by  pure  tincture 
of  iodine,  solution  of  nitrate  of  silver,  or  solution  of  persulphate  of  iron 
diluted  with  two  or  three  equivalents  of  water.  As  a  full  discussion  as  to 
the  dangers  of  intrauterine  injections  will  be  found  elsewhere,  I  shall  not 
enter  upon  the  subject  here. 

Should  caustic  treatment  by  strong  acid  be  determined  upon,  the  cer- 
vical speculum  should  be  passed  through  the  neck  to  protect  this  part,  and 
preserve  the  acid  for  energetic  action  on  the  lining  membrane  of  the  body. 
In  many  cases  replacement  and  support  of  a  displaced  uterus  will  serve 
to  relieve  a  prolonged  metrorrhagia,  while  the  same  results  will  be  pro- 
duced in  others  by  cure  of  a  granular  and  bleeding  cervix,  or  the  repair  of 
a  lacerated  one. 

All  disorder  of  the  blood  should  be  combated  by  appropriate  constitu- 
tional means,  even  where  it  is  secondary  to  the  loss,  and  not  a  primary 
cause  of  it.  Where  the  hemorrhage  is  due  to  a  polypus,  the  resulting 
impoverishment  of  the  blood  renders  escape  of  the  vital  fluid  more  easy 
and  rapid. 

In  very  obstinate  cases  a  change  from  a  warm  to  a  cold  climate,  and 
from  the  lowlands  to  a  mountainous  region,  often  accomplishes  a  great 
deal  of  good. 

I  feel  very  sure  that  in  menorrhagia  a  great  deal  of  harm  results  from 
the  frequent  use  of  iron  and  quinine.  These  drugs  are  given  to  repair  the 
damage  done  to  the  blood,  but  both  of  them  increase  uterine  congestion, 
and  tend  to  aggravate  the  flow. 


CHAPTER    XLII. 

AMENORRHEA. 

Definition Amenorrhea,   a  term   derived  from  a,   privative,  pqv  "  a 

month,"  and  jjtw,  "  I  flow,"  implies  an  absence  of  the  menstrual  flow  in  a 
woman  in  whom  it  should  naturally  exist.  Such  an  absence  before  pu- 
berty, after  the  menopause,  or  during  pregnancy  and  lactation,  is  the  nor- 
mal condition,  and  hence  does  not  come  within  the  definition. 

>  Op.  cit.,  p.  473.  2  Op.  cit.,  p.  242.  »  Op.  cit.,  p.  254. 


636  AMENORRHEA. 

Frequency. — It  is  an  affection  of  great  frequency  among  women  who 
live  luxurious  and  indolent  lives,  and  disorder  the  nervous  and  sanguineous 
systems  by  neglect  of  those  habits  which  keep  them  in  a  state  of  health. 
Hence  it  is  very  frequently  encountered  among  the  members  of  the  higher 
classes  of  civilized  society  all  over  the  world. 

Varieties. — If  the  habitual  monthly  discharge  be  suddenly  checked,  the 
disorder  is  styled  suppressio-mensium;  and  if  the  discharge  have  never 
appeared  in  a  woman  who  ought  to  menstruate  regularly,  it  is  called 
emansio-mensium. 

Pathology — That  the  discharge  of  blood,  which,  occurring  at  monthly 
periods,  constitutes  menstruation,  is  a  true  hemorrhage  dependent  upon 
the  process  of  ovulation,  is  now  regarded  as  a  settled  fact  by  most  physi- 
ologists. In  accordance  with  a  law  of  nature  which  we  recognize  in  its 
effects  but  cannot  explain,  once  in  every  twenty-eight  days  one  or  more 
ovules  in  each  ovary  burst  their  envelopes,  and  entering  the  Fallopian 
tubes  pass  downwards  to  the  uterus.  This  eruption  of  ovules  produces  in 
the  ovaries  congestion  and  nervous  exaltation,  which  continue  until  the 
process  is  completed. 

No  sooner  are  these  organs  thus  affected  than,  through  the  instrumen- 
tality of  the  ganglionic  system  of  nerves  connecting  them  with  the  uterus, 
that  organ  sympathetically  undergoes  congestion  likewise.  The  whole 
uterus  becomes  heavy  and  descends  perceptibly  in  the  pelvis ;  its  mucous 
membrane  is  swollen  and  turgid,  and  the  vessels  which  supply  it  dilate 
under  an  excessive  hyperemia,  as  do  those  of  the  conjunctiva  in  conjunc- 
tivitis ;  then  a  rupture  occurs  and  relief  is  obtained  by  hemorrhage.  For 
the  proper  performance  of  the  function  three  elements  must  exist  in  a 
perfect  state  of  integrity:  1st,  the  uterus,  ovaries,  and  vagina  must  be 
perfect  in  form  and  vigor ;  2d,  the  blood  must  be  in  its  normal  state ;  and 
3d,  the  nervous  system  governing  the  relations  between  the  uterus  and 
ovaries  must  be  unimpaired  in  tone. 

Any  influence  disordering  one  or  more  of  these  may  check  ovulation, 
the  great  moving  cause  of  the  function ;  prevent  the  degree  of  sympathetic 
congestion  necessary  for  rupture  of  uterine  vessels;  or  oppose  the  discharge 
of  blood  which  has  been  effused. 

The  non-performance  of  the  function  of  menstruation  was  formerly,  and 
even  now  is  by  some,  regarded  as  productive  of  many  constitutional  evils, 
as,  for  example,  chlorosis,  phthisis,  dropsical  effusions,  etc.  It  is  highly 
probable  that  in  these  deductions  the  effect  has  been  mistaken  for  the 
cause.  The  impoverished  blood,  and  nervous  derangement  attendant 
upon  these  affections,  result  in  failure  of  that  function.  No  proof  exists 
which  can  substantiate  the  view  that  amenorrhoea  ever  induces  permanent 
lesion  of  any  organ  in  the  body. 

Causes After  what  has  been  already  stated,  the  causes  of  the  affection 

may  be  tabulated  without  fear  of  confusing  the  reader. 


causes.  G37 

Amenorrhea  may  result  from  any  of  the  following  conditions: — 
Abnormal  states  of  organs  of  generation. 
Absence  of  uterus  or  ovaries  ; 
Rudimentary  uterus  or  ovaries  ; 
Occlusion  of  uterus  or  vagina  ; 
Uterine  atrophy ; 
Pelvic  peritonitis ; 
Atrophy  of  both  ovaries  ; 
Cystic  degeneration  of  both  ovaries. 
Abnormal  states  of  the  blood. 
Chlorosis  ; 
Plethora  ; 

Blood  state  of  phthisis  ; 
"         "     of  cirrhosis  ; 
"        "    of  Bright's  disease,  etc. 
Abnormal  state  of  ganglionic  nervous  system. 
Atony  from  mental  depression  ; 
"  "     indolence  and  luxury  ; 

"  "     want  of  fresh  air  and  exercise  ; 

"  "     constitutional  diseases,  as  phthisis,  etc. 

Complete  absence  of  the  internal  organs  of  generation  is  very  infrequent, 
though  a  rudimentary  condition  is  less  rare.  With  reference  to  absence 
of  the  uterus,  Scanzoni  remarks  :  "  On  carefully  analyzing  the  reported 
cases  of  entire  absence  of  the  womb,  we  find  that  almost  always  some 
rudiments  of  this  organ  still  exist,  so  that  authenticated  and  unquestion- 
able instances  of  this  anomaly  are  extremely  rare."  He  further  declares 
that  he  has  never  been  able  to  authenticate  a  single  case.  I  have  seen 
one  instance  presented  by  Prof.  I.  E.  Taylor  to  the  Obstetrical  Society  of 
this  city,  in  which  no  trace  of  the  uterus  could  be  detected  upon  the  closest 
scrutiny  of  the  parts  removed  post  mortem. 

Absence  of  both  ovaries  is  quite  rare.  They  are  most  frequently  found 
to  be  in  a  rudimentary  condition  resembling  their  fetal  state. 

The  vagina  may  be  occluded  by  an  obturator  hymen,  contraction  from 
inflammation  and  sloughing,  or  from  congenital  or  acquired  atresia. 

So  likewise  may  the  canal  of  the  cervix  uteri  be  congenitally  or  acci- 
dentally closed. 

What  I  have  styled  atony  of  the  nervous  system  has  been  well  described 
by  Prof.  Hodge,  of  Philadelphia,  under  the  name  of  sedation.  It  consists 
in  a  decrease  of  the  excitability,  vigor,  and  activity  of  the  nervous  agency 
which  controls  the  functions  of  different  organs,  and  has  for  its  cause  phy- 
sical and  moral  influences,  some  of  which  have  been  enumerated.  Some 
of  the  functions  which  are  under  the  control  of  the  ganglionic  system  are, 
the  action  of  the  heart,  digestion,  peristalsis,  and  regulation  of  animal 
heat.     In  one  leading  a  natural  and  healthy  life,  in  the  country  for  ex- 


638  AMENORRHEA. 

ample,  all  these  are  likely  to  be  normally  performed ;  but  if  the  same 
individual  remove  to  a  crowded  city,  lead  the  life  of  a  student,  exhaust  his 
nerve  power  by  late  hours,  bad  air,  and  mental  efforts,  all  of  them  rapidly 
become  deranged.  He  suffers  from  palpitation  of  the  heart,  dyspepsia, 
coldness  of  hands  and  feet,  and  constipation.  This  change  usually  occurs 
slowly,  but  sometimes  it  does  so  rapidly,  as  from  a  sea-voyage  or  any  very 
violent  mental  strain.  In  a  similar  manner  the  processes  of  ovulation  and 
menstruation  are  affected  by  it,  in  some  cases  gradually,  in  others  with 
great  rapidity. 

Differentiation Before  treatment  is  instituted  for  this  condition,  it 

must  be  carefully  differentiated  from — 
Pregnancy ; 
The  menopause ; 
Tardy  menstruation. 

The  first  will  be  readily  recognized  by  its  characteristic  signs,  if  sus- 
picion be  awakened,  and  they  be  investigated.  Very  often  no  such  sus- 
picion arising,  the  criminal  desires  of  some  women  are  gratified,  and  the 
hopes  of  others  blighted  through  the  unintentional  induction  of  abortion 
by  the  treatment  adopted. 

The  law  with  regard  to  the  menopause  is,  that  it  should  occur  between 
the  ages  of  forty  and  fifty,  but  it  is  sometimes  delayed  until  sixty  or 
seventy,  and  at  others  take  place  at  a  very  early  age.  It  may  occur  as 
early  as  the  twenty-first  year,  and  in  twenty-seven  out  of  forty-nine  cases 
of  early  cessation  collected  by  Dr.  Tilt,1  it  took  place  from  the  twenty- 
seventh  to  the  thirty-ninth  year.  The  absence  of  sensations  of  discomfort 
at  the  periods  when  the  menses  should  occur,  will  help  to  lead  the  practi- 
tioner to  a  correct  conclusion  as  to  the  character  of  the  case. 

Sometimes  mothers  will  be  much  alarmed  by  absence  of  the  function  in 
girls  at  fifteen  or  sixteen  years.  It  should  be  remembered  that  it  is  not 
very  rare  for  it  to  be  delayed  until  those  ages.  Differentiation  should  be 
accomplished  under  these  circumstances  as  under  the  last  mentioned. 

Treatment. — From  what  has  been  already  said,  it  is  manifest  that  ame- 
norrhoea  is  not  a  disease,  but  a  symptom  of  some  local  or  general  disorder, 
and  it  follows  that  all  efforts  directed  simply  to  re-establishment  of  the 
absent  function,  must  necessarily  be  empirical.  The  cause  should  be  dis- 
covered, and,  if  possible,  removed.  Should  it  be  susceptible  of  removal, 
the  method  appropriate  for  accomplishing  this  will  be  evident,  while  if  it 
depend  upon  an  incurable  condition,  great  benefit  will  be  gained  by  the 
avoidance  of  means  previously  practised  in  the  vain  hope  of  establishing 
the  flow,  and  by  our  ability  to  place  the  mind  of  the  patient  beyond  the 
harassing  influence  of  suspense. 

If  the  uterus  be  found  to  be  absent,  all  that  can  be  done  will  be  to  ab- 

•  On  Uterine  and  Ovarian  Inflammation,  p.  54. 


TREATMENT.  039 

stract  a  sufficient  amount  of  blood  from  the  arm  by  venesection,  if  neces- 
sary, to  relieve  the  urgent  symptoms  attending  each  epoch. 

Occlusion  of  the  vagina  or  cervix  should  be  treated  by  surgical  means, 
the  barrier  being  overcome  by  the  knife,  scissors,  or  trocar. 

In  case  a  rudimentary  or  atrophied  uterus  be  discovered  as  the  source 
of  the  affection,  attempts  should  be  made  to  develop  it  by  local  stimulation 
and  distention.  At  short  intervals  it  should  be  fully  distended  by  a  tent, 
in  order  that  an  increase  of  nutrition  and  consequent  increase  of  volume 
and  capacity  may  be  excited.  When  this  plan  is  not  in  operation,  an 
intrauterine  galvanic  pessary  may  be  kept  in  utero  for  the  furtherance  of 
the  same  end.  It  is  astonishing  how  much  development  may  be  obtained 
by  a  persevering  practice  of  this  plan.  In  many  instances  it  will  restore 
the  uterus  to  its  original  size,  and  cause  a  return  of  the  menstrual  flow. 
But  it  often  requires  considerable  time  to  bring  about  so  favorable  a  result ; 
even  years  may  elapse  before  it  is  fully  attained. 

If  it  be  decided  that  the  non-performance  of  the  function  is  due  to  ple- 
thora, anaemia,  or  chlorosis,  these  states  should  be  treated  ;  the  first  by 
venesection,  strict  diet,  exercise,  and  a  life  in  the  open  air ;  the  second 
and  third  by  change  of  air,  rich  food,  exercise,  and  ferruginous  tonics.  In 
plethora.  Prof.  Bedford  speaks  highly  of  the  abstraction  of  blood  from  the 
arm  at  intervals  of  a  month,  the  abstraction  being  performed  between  the 
menstrual  epochs. 

Should  some  grave  constitutional  condition  like  tuberculosis  or  the  others 
mentioned,  be  found  to  be  the  main  morbid  state,  it,  and  not  its  resulting 
symptom,  should  attract  attention. 

An  atonic  state  of  the  nervous  system  governing  menstruation  should 
be  treated  by  a  resort  to  a  general  tonic  course.  Among  the  means  appli- 
cable to  its  removal  may  be  especially  mentioned,  exercise  on  foot  and 
horseback,  rowing,  calisthenics,  sea-bathing,  nutritious  food,  and  nervous 
tonics  of  medical  character,  as  nux  vomica,  strychnine,  quinine,  and  the 
general  use  of  electricity.  It  is  in  this  class  of  cases  that  many  drugs  and 
prescriptions  styled  emmenagogue  have  often  succeeded  in  restoring  the 
function  even  when  used  empirically.  A  state  of  general  nervous  atony 
is  frequently  attended  by  chlorosis  and  always  by  constipation.  The  ner- 
vous disorder  and  two  of  its  resulting  symptoms  may  be  favorably  affected 
by  the  stereotyped  combination  of  aloes,  iron,  and  myrrh  or  nux  vomica; 
and  the  sluggish  nerve  power  may  be  temporarily  excited  to  the  perform- 
ance of  its  duties  by  the  administration  of  tansy,  rue,  ergot,  or  savine. 
But  it  is  not  through  desultory  means  of  this  character  that  a  cure  can  be 
anticipated  with  any  confidence.  A  more  comprehensive  plan  directed  to 
the  improvement  of  the  patient's  constitution  should  be  adopted  and  sys- 
tematically pursued.  As  general  means  those  already  mentioned  will 
always  be  found  highly  useful.  If  the  patient  while  at  home  cannot  be 
prevailed  upon  to  practise  sufficient  self-denial  to  avoid  what  is  injurious, 


640  AMENORRHEA. 

or  be  made  to  develop  the  energy  necessary  to  follow  a  course  which 
requires  effort,  she  may,  with  great  advantage,  be  placed  for  a  time  in  a 
well-regulated  hydropathic  establishment,  where  the  early  hours  of  retiring, 
simple  food,  exercise,  society,  pure  air,  and  bathing,  will  accomplish  a 
roborant  effect  which  will  prove  of  great  value  in  the  cure  of  the  affection. 
But  not  merely  should  constitutional  means  be  adopted.  After  the 
general  condition  has  been  improved,  local  stimuli  may  be  resorted  to  with 
great  benefit.     Those  which  will  be  found  to  be  most  efficient  are — 

Passage  of  the  sound  ; 

Tents ; 

Cupping ; 

Electricity ; 

Stimulating  enemata ; 

Baths. 
In  their  action  these  means  probably  exert  an  influence  not  only  on  the 
uterus,  but  sometimes  by  their  stimulating  effects  excite  the  process  of 
ovulation.  The  sound  should  be  passed  up  to  the  fundus  once  every  day 
for  three  or  four  days  before  the  expected  flow ;  or  if  the  process  of  ovula- 
tion do  not  demonstrate  its  existence,  it  may  be  passed  once  a  week 
throughout  the  month.  At  the  same  periods  tents  of  tupelo  or  sea-tangle 
may  be  used,  the  dangers  attending  them  being  always  borne  in  mind 
during  their  employment. 

The  cervix  uteri  may,  by  the  application  of  an  exhauster  or  dry  cup, 
have  a  marked  hyperemia  excited  within  it,  which  extends  to  the  uterine 
body  and  replaces  that  which  should  have  occurred  from  physiological 
causes.  A  very  simple  method  for  producing  it  is  to  enclose  the  cervix 
within  the  mouth  of  the  cylinder  of  hard  rubber  represented  in  Fig.  246, 
and  then  exhaust  the  air  by  withdrawing  the  piston. 

Fig.  246. 


Syringe  for  dry  cupping  the  cervix. 

Before  the  introduction  of  this  instrument  the  uterus  should  be  exposed 
by  means  of  the  speculum.  In  this  way  I  have  repeatedly  drawn,  with- 
out effort,  one  or  two  drachms  of  blood  through  the  mucous  lining  of  the 
neck. 

Electricity  is  a  means  of  great  value.  One  pole  of  a  battery  may  be 
applied  over  the  lower  portion  of  the  spine  and  the  other  passed  over  the 
hypogastrium,  placed  in  contact  with  the  cervix,  or  even  carried,  by 
means  of  a  wire  covered,  except  for  its  terminal  three  inches,  with  a  gum- 
elastic  catheter,  up  to  the  fundus  of  the  uterus.  For  the  purpose  of  keep- 
ing up  a  mild  but  steady  current  within  the  uterus,  Prof.  Simpson  has 


TREATMENT.  (541 

advised  a  stem  composed  of  copper  for  one  half  its  length  and  zinc  for  the 
other  half,  which  is  passed  up  to  the  fundus.  It  has  an  ovoid  disk  at  its 
lower  extremity  upon  which  the  cervix  rests.  Dr.  Noeggerath  has  made 
an  improvement  in  this  by  having  the  stem  composed  of  two  parallel 
pieces  of  copper  and  zinc,  instead  of  two  short  pieces  of  these  metals 
united  at  the  centre  of  the  stem.  As  these  instruments  must  be  left  in 
place  while  the  patient  walks  about,  there  is  always  danger  of  their  irri- 
tating the  walls  of  the  uterus  to  too  great  an  extent.  To  avoid  this  I 
have  employed  a  stem  composed  of  alternate  beads  of  copper  and  zinc, 
held  together  by  a  small  wire  rope,  which  passes  through  the  centre  of 
each,  and  is  secured  to  the  uppermost  and  to  the  vaginal  disk  below. 
This  may,  by  any  movement  of  the  uterus,  be  bent  at  the  required  angle, 
and  consequently  can  do  no  injury.  (Fig.  247.)  The 
disk  or  bulb  of  this  instrument  should  be  made  globular  Fig.  247. 

so  as  to  rest  in  the  cup  held  between   the  branches  of  a 
Hodge  or  Smith  pessary,  as  shown  in  Fig.  197. 

As  an  excitant  of  the  menstrual  flow,  enemata  of  very 
warm  water  impregnated  with  chloride  of  sodium,  aloes, 
or  soap,  constitute  a  valuable  resource.  Not  only  does 
the  medicinal  substance  irritate  the  uterine  nerves,  the  Galvanic  pessary 
warm  fluid  brought  into  close  contact  with  the  uterus  also 
excites  a  flow  of  blood  to  it.  Hip-baths  and  pediluvia  have  lon^  been 
resorted  to  for  the  purpose  of  exciting  menstruation.  They  should  be 
prolonged,  and  as  warm  as  the  patient  can  bear  them.  In  addition  to 
these  means,  copious  injections  of  warm  water  may  with  benefit  be  thrown 
into  the  vagina,  one  or  two  gallons  being,  by  means  of  a  proper  syringe, 
projected  against  the  os  uteri. 

Reasoning  from  analogy  and  from  our  knowledge  of  the  physiology  of 
menstruation,  we  are  unquestionably  warranted  in  the  deduction  that  in  a 
certain  number  of  cases  amenorrhea  is  due  to  non-performance  of  the 
function  of  ovulation.  It  is  not  possible  to  give  clinical  evidence  of  the 
fact,  but  it  may  be  strongly  surmised  when  none  of  the  symptoms  usually 
attendant  upon  this  process  present  themselves  at  monthly  periods.  The 
means  by  which  it  should  be  treated  are  those  already  advised,  for  any 
of  the  causes  mentioned  may  produce  that  variety  of  the  affection  which 
is  due  to  non-performance  of  ovarian  functions,  in  the  same  manner  that 
they  give  rise  to  that  form  depending  upon  the  incapacity  of  the  uterus. 

In  many  cases  where,  in  spite  of  well  directed  efforts,  eight,  ten,  and 
twelve  months  will  elapse  without  signs  of  menstruation,  and  this  on  re- 
peated occasions,  it  is  useless  to  continue  efforts  such  as  those  which  have 
been  mentioned.     The  case  is  often  better  left  to  nature. 

41 


642  LEUC0RRHG5A. 


CHAPTER  XLIII. 

LEUCORRHCEA. 

Ix  my  anxiety  to  impress  the  importance  of  regarding  and  treating  this 
condition  as  a  symptom  of  uterine  or  vaginal  disease,  and  not  as  a  primary 
affection,  I  have  been  in  great  doubt  as  to  the  propriety  of  devoting  a 
separate  chapter  to  it.  In  doing  so  I  confess  that  I  yield  to  a  conven- 
tional practice  which  I  do  not  fully  indorse,  and  I  offer  this  fact  as  an 
explanation  of  any  superficiality  in  the  treatment  of  the  subject  which 
may  strike  the  reader.  I  feel  very  sure  that  the  writer  of  fifty  years  hence 
will  omit  the  separate  consideration  of  this  symptom  entirely. 

Definition This  affection,  the  name  of  which  is  derived  from  juvxoj, 

"white,"  and  £fu,  "I  flow,"  consists  in  a  whitish,  yellowish,  or  greenish 
mucous  discharge  from  the  vagina. 

Synonyms. — It  has  been,  in  modern  times,  described  under  the  names 
of  fluor  albus,  blennorrhea,  pertes  blanches,  fleurs  blanches,  and  whites. 
In  ancient  literature  the  variety  of  names  which  was  applied  to  it  may  be 
judged  of  when  it  is  stated  that  over  fifty  appellations  were  at  different 
times  employed  in  designating  it. 

Frequency No  disease  or  symptom  in  the  whole  list  of  female  ills  is 

so  common.  Probably  no  woman  ever  goes  through  life  without  at  some 
period,  and  for  a  variable  time,  suffering  from  it.  It  is  only  when  it 
becomes  annoying  by  its  constancy,  abundance,  or  irritating  properties 
that  it  attracts  attention  and  causes  the  patient  to  seek  assistance. 

History In  the  earliest  writings  of  the  Greek  school  and  throughout 

Roman  and  Arabian  medical  literature,  abundant  descriptions  of  this  dis- 
order may  be  found.  Hippocrates  described  it,  pointing  out  as  among  its 
symptoms,  puffiness  of  the  face,  paleness,  and  enlargement  of  the  abdomen. 
He  evinces  a  familiarity  with  its  treatment  by  an  admission  of  the  diffi- 
culty of  curing  it.  Areta:us  of  Cappadocia,  in  the  first  century,  mentioned 
the  varieties  of  leucorrhcea,  as  to  color,  quantity,  etc.,  and  Aetius  and 
Paul  of  TKgina  speak  of  two  forms  of  the  affection,  red  and  white  flux. 
For  the  latter,  Aetius  recommends  jicst^ijon,  vociferation,  walking,  etc. 
The  Arabians,  Ilaly  Abbas  and  Alsaharavius,  wrote  upon  the  subject, 
but  advanced  nothing  new. 

As  in  ancient  times,  so  also  in  modern,  it  has  attracted  a  great  deal  of 
attention,  and  until  the  establishment  of  the  present  school  of  gynecology 
by  Recamier,  was  treated  of  as  a  disease  rather  than  as  a  symptom.     Even 


VARIETIES.  043 

long  after  this  period  it  was  commonly  regarded  as  a  disease  ;  the  result 
of  constitutional  debility,  or  the  index  of  an  impure  blood  r,tate.  For  the 
views  which  are  now  entertained  concerning  it,  we  are  indebted  to  no  one 
so  much  as  to  Dr.  J.  II.  Bennet,  of  London,  who,  by  his  forcible  reason- 
ing, supported  by  clinical  evidence,  clearly  demonstrated  its  ordinary  de- 
pendence as  a  symptom  upon  some  local  lesion.  Dr.  Tyler  Smith,  in  an 
elaborate  essay  upon  the  subject,  has  also  done  much  to  elucidate  certain 
points  in  its  pathology,  which  before  his  time  had  been  undeveloped. 

Pathology. — As  a  discharge  of  mucus  or  muco-pus  is  a  symptom  of 
urethritis,  bronchitis,  nasal  catarrh,  and  faucitis,  so  is  it  a  symptom  of 
inflammation  of  the  vagina  and  lining  membrane  of  the  uterus  and  Fallo- 
pian tubes.  Whatever  influence  is  capable  of  creating  it  elsewhere  may 
give  rise  to  it  here,  and  in  this  position  it  is,  as  it  is  elsewhere,  only  an 
isolated  sign  of  a  pathological  state.  It  is  not  by  any  means,  however, 
always  an  evidence  of  inflammatory  action.  As  many  individuals  upon 
exposure  to  cold  will  freely  discharge  mucus  from  the  nostrils  without 
any  inflammation  existing,  so  will  many  women  suffer  from  leucorrhcea 
from  any  cause  producing  a  temporary  congestion  of  the  mucous  mem- 
brane. But  in  these  cases  tlie  disease  is  temporary,  following  or  pre- 
ceding the  menstrual  congestion,  or  arising  from  fatigue  or  exhaustion. 
When  it  becomes  permanent  and  the  discharge  grows  profuse  or  acrid,  its 
connection  with  a  morbid  state  is  rendered  probable.  At  such  times  it  is 
always  a  symptom  of  some  abnormal  condition  of  the  uterus,  Fallopian 
tubes,  or  vagina,  and  its  presence  should  lead  to  an  investigation  of  these 
organs, 

Any  agency  which  moderately  increases  vascular  activity  in  a  secreting 
organ  tends  to  augment  the  amount  of  its  secretion.  I  say  moderately 
increases,  because  an  excessive  turgescence,  such  as  attends  upon  acute 
inflammation,  checks  secretion  entirely.  Such  an  influence  being  exerted 
upon  any  part  of  the  mucous  covering  of  the  generative  canal  of  the  female, 
an  excessive  flow  of  plasma,  together  with  a  rapid  exfoliation  of  epithelial 
cells  and  the  formation  of  pus-corpuscles,  results. 

Varieties Leucorrhcea  is  divided  into  two  varieties,  according  to  its 

origin — vaginal  and  uterine.  Either  of  these  may  exist  separately,  or 
the  two  may  coexist.  If  it  be  vaginal,  it  may  continue  as  such  for  a 
length  of  time.  If  the  inflammatory  action  producing  the  discharge  be 
confined  to  the  uterine  mucous  membrane,  it  may  remain  so  without  im- 
plicating the  vagina,  but  that  canal  receiving  the  products  of  uterine 
secretion  is  generally  excited  into  morbid  action.  A  similar  result  may 
frequently  be  observed  in  nasal  catarrh  in  children,  the  upper  lip  being 
bereft  of  its  epithelial  investment,  and  a  papular  or  vesicular  eruption 
excited  over  the  neighboring  parts  of  the  face. 

Vaginal  leucorrhcea  consists  of  a  white,  creamy,  purulent  looking  fluid, 


044 


LEUCORRHCEA. 


which  is  composed,  according  to  Dr.  Tyler  Smith,  of  the  following  ele- 
ments : — 

Acid  plasma ; 

Scaly  epithelium  ; 

Pus  corpuscles  ; 

.Blood  globules ; 

Fatty  matter. 
Under  the  microscope  it  appears  as  represented  in  Fig.  248. 

Fig.  248. 


Vaginal  lencorrhrea  tinder  the  microscope.     (Smith.) 

That  arising  from  the  canal  of  the  cervix  is  thick,  tenacious,  and  ropy, 
like  the  white  of  an  eg^  and  consists  of — 

Alkaline  plasma ; 

Mucous  corpuscles  ; 

Altered  cylindrical  epithelium  ; 

Pus  corpuscles ; 

Blood  globules ; 

Fatty  particles. 
Examined  by  the  microscope  it  presents  the  appearance  shown  in  Fig. 
249. 

That  arising  from  the  body  of  the  uterus  resembles  the  cervical  form, 
except  that  it  is  less  gelatinous,  less  ropy,  and  more  likely  to  be  tinged 
with  blood. 

Causes. — Any  pathological  state  which  keeps  up  in  the  uterus  a  con- 
dition of  engorgement  ending  in  inflammation,  or  simply  in  retarded  and 
enfeebled  circulation,  may  create  leucorrhcea  as  a  symptom.  Prominent 
among  these  may  be  mentioned — 

Subinvolution  of  uterus  ; 

Suppressed  menstruation  ; 

Fibroids,  polypi,  or  fungous  vegetations; 


TREATMENT, 


045 


Prolonged  lactation  ; 

Gestation  and  parturition; 

Excessive  coition  ; 

Anaemia ; 

Uterine  displacement  ; 

Laceration  and  eversion  of  cervix  ; 

Endometritis,  corporeal  or  cervical ; 

Granular  degeneration  ; 

Syphilitic  ulceration  ; 

Vaginitis,  specific  or  simple  ; 

Habitual  constipation  ; 

Toxaemia  from  malaria,  uraemia,  or  scout. 


<!£> 


Fig.  249. 


^K^'a 


'CE> 


Cervical  leucorrhcca  uuder  the  microscope.     (Smith  ) 

It  will  thus  be  seen  that  the  disorder  may  in  some  instances  be  a  trivial 
matter,  which,  by  a  judicious  combination  of  general  and  local  means,  will 
rapidly  disappear,  while  in  many  others  it  is  an  attendant  circumstance  of 
some  grave  pathological  state  of  the  uterus  or  vagina,  and  conserpiently 
difficult  of  cure. 

Progiiosis. — This  will  depend  in  great  degree  upon  the  cause.  If  this 
can  be  readily  removed,  the  prognosis  will  be  favorable  ;  while  if  it  be 
connected  with  some  serious  organic  lesion,  it  will  not  be  so. 

Results Uterine  leucorrhcca  may  result  in — 

Sterility; 

Vaginitis  ; 

Pruritus  vulvas  ; 

Vulvitis  ; 

Salpingitis  ; 

Granular  degeneration. 

Treatment When   a  patient  applies   to  a  practitioner  for  the  cure  of 

leucorrhoea,  it  should  be  his  first  endeavor  to  discover  the  cause  of  the 
muco-purulent  flow.     A  suspicion  as   to  the  source  of  the   difficulty  may 


646  LEUCORRHCEA. 

ordinarily  be  based  upon  examination  into  the  rational  signs,  but  a  diag- 
nosis of  the  condition  which  gives  rise  to  the  symptom  which  has  excited 
anxiety  in  the  mind  of  the  patient  can  be  more  certainly  arrived  at  by 
physical  exploration.  If  upon  this,  disease  of  the  uterus,  vagina,  or  Fallopian 
tubes  be  discovered  to  exist,  either  in  the  form  of  inflammation  or  conges- 
tion, this  affection  should  receive  appropriate  treatment.  To  recapitulate 
the  plans  which  should  be  pursued  would  here  be  entirely  out  of  place, 
for  they  are  laid  down  in  other  parts  of  this  work  in  connection  with  the 
special  disorders  of  these  parts.  Suffice  it  here  to  say  that  the  condition 
underlying  the  symptom  leucorrhoea  should  receive  treatment  always. 
Sometimes  the  application  of  the  curette,  the  operation  of  trachelotomy  or 
of  trachelorrhaphy,  the  replacement  of  a  displaced  uterus,  or  the  removal 
of  a  submucous  tumor  will  cut  short  a  treatment  which  might  otherwise  be 
prolonged  for  years. 

As  to  general  treatment,  a  course  especially  adapted  to  giving  tone  to 
the  dilated  bloodvessels  of  the  mucous  membrane,  and  overcoming  the 
tendency  to  excessive  creation  of  cells  and  exudation  of  blood  plasma, 
should  in  addition  be  adopted.  To  begin  with,  the  patient  should  be  put 
upon  general  tonic  treatment,  such  as  the  use  of  quinine,  Peruvian  bark, 
strychnine,  and  iron  ;  sea-bathing ;  change  of  air  and  scene ;  and  the 
substitution  of  quiet  and  cheerful  social  influences  for  those  which  are 
exciting  or  depressing.  The  diet  should  also  be  made  nutritious  and 
simple,  and  all  stimulants,  spices,  and  condiments  be  strictly  avoided. 

"When  the  vagina  is  affected,  that  canal,  after  having  been  carefully 
cleansed,  should,  by  means  of  a  rod  wrapped  with  cotton,  be  thoroughly 
washed  over  with  a  solution  of  the  nitrate  of  silver,  one  part  to  eight  or  ten 
of  water.  After  this  a  tampon  of  cotton  saturated  with  glycerine  should 
be  left  in  the  canal  for  twenty-four  hours  and  removed  by  the  patient,  a 
thread  being  attached  to  it  for  this  purpose.  Then  copious  astringent  and 
soothing  vaginal  injections  should  be  employed  night  and  morning.  The 
best  astringents  for  this  purpose  are  alum,  tannin,  infusion  of  oak  bark, 
zinc,  and  lead.     As  examples  of  good  combinations,  I  give  the  following : — 

R. — Acidi  tannici,  Jiv. 
G  \y cer  i  n  «*e ,  §  x  v j . — M . 
S. — A  tablespoonful  to  a  quart  of  tepid  water,  to  be  used  as  a  vaginal  injection 
for  five  minutes  every  night  and  morning  by  means  of  one  of  the  syringes  recom- 
mended. 

R. — Cupri  sulphat.  3JSS- 
Zinci  sulphat.  3JSS- 
Aluminis  sulphat.  3JSS- 
Glycerinne,  §vj. — M. 
Follow  same  directions  as  those  given  above. 

One  drachm  of  boracic  acid  to  a  pint  of  warm  water,  half  a  drachm  of 
hydrate  of  chloral  or  half  an  ounce  of  the  fluid  extract  of  pinus  Canadensis 
to  the  same  also  answer  an  excellent  purpose. 


TREATMENT.  647 

Once  a  week  the  application  of  the  solution  of  nitrate  of  silver,  in 
diminishing  strength,  should  be  repeated  and  followed  by  the  use  of  the 
tampon  of  cotton  soaked  in  glycerine,  or  glycerine  and  tannin,  until  the 
leucorrhoea  is  cured.  Cure  will  commonly  be  effected  by  these  means,  if 
no  other  disorder  exist  to  reproduce  a  symptom  which  it  has  once  proved 
itself  efficient  to  establish.  If  such  a  condition  exist  and  be  overlooked  by 
the  practitioner,  it  will  inevitably  cause  again  what  it  did  before.  Neither 
plan  should  be  despised — treatment  of  the  causative  disorder  nor  that  of  the 
resulting  symptom  ;  and  by  a  combination  of  the  two  plans  better  results 
will  be  obtained  than  could  be  accomplished  by  an  exclusive  adherence 
to  either. 

In  cases  of  chronic  vaginitis,  astringents  sometimes  appear  to  do  harm, 
and  infusions  of  flaxseed,  slippery  elm,  and  similar  substances  often  prove 
beneficial.  On  the  other  hand,  in  the  treatment  of  chronic  endometritis, 
it  will  often  be  found  of  benefit  to  use  astringent  injections  which  act  not 
only  by  securing  cleanliness,  but  by  hardening  the  vaginal  mucous  mem- 
brane and  preventing  the  complication  of  vaginitis  as  a  result  of  uterine 
catarrh. 

As  a  general  outline,  the  following  may  be  given  as  a  plan  of  treat- 
ment : — 

1st.  Keep  the  uterus  in  perfect  position  by  a  pessary  if  it  be  decidedly 
displaced ; 

2d.  By  appropriate  cathartics,  keep  the  portal  circulation  free  and  the 
rectum  emptied  of  feces  ; 

3d.  Cure  laceration  of  the  cervix  if  it  exist,  and  remove  polypi  and 
fungosities  ; 

4th.  Remove  all  weight  from  the  uterus  from  above,  and  all  traction 
from  it  from  below  ; 

5th.  Keep  the  cutaneous  circulation  active  by  baths,  friction,  exercise, 
and  pure  air ; 

6th.  Keep  the  blood  and  nerve  states  normal  by  tonics,  exercise,  etc.  ; 

7th.  Counteract  all  toxoemic  influences,  such  as  malarial,  (whether 
palludal  or  from  sewer  emanations),  uraemic,  scorbutic,  rheumatic,  or 
arthritic  ; 

8th.  Keep  the  menstrual  function  normal  by  careful  supervision  ; 

9th.  In  case  cardiac  disease,  aneurism,  hepatic  disease,  pelvic  peri- 
tonitis, or  perimetric  cellulitis  are  primary  causes  of  it,  recognize  the 
futility  of  local  treatment,  and  do  not  annoy  the  patient  by  a  resort  to  it. 

To  enter  more  minutely  into  the  treatment  of  leucorrhoea  would  be  to 
defeat  the  main  object  which  I  have  had  in  view,  that  of  subordinating 
the  consideration  of  this  disorder  to  that  of  the  diseased  states  which 
produce  it. 


648  STERILITY. 


' 


CHAPTER    XLIV. 

STERILITY. 

Definition  and  Synonyms — This  term,  which  is  derived  from  attpcoi, 
"barren,"  and  implies  an  incapacity  for  conception,  is  synonymously 
entitled  barrenness  and  infecundity. 

History — Throughout  medical  literature,  from  the  earliest  periods  to 
the  present,  it  has  attracted  special  attention,  and  been  the  subject  of 
dissertations  by  all  authors  who  have  touched  upon  the  affections  peculiar 
to  females.  The  frequent  reference  made  to  it  by  Biblical  writers  as  a 
reproach  to  women,  is  too  well  known  to  require  special  mention. 

Causes — To  comprehend  the  pathology  of  sterility,  the  physiology  of 
conception  must  be  clearly  understood.  In  the  act  of  coition  the  male 
organ,  being  introduced  into  the  vagina,  projects  into  and  against  the 
cervix  a  fluid,  consisting  of  a  thick,  watery  portion,  holding  in  suspension 
large  numbers  of  ciliated  cells  which  have  the  power  of  moving  by  ciliary 
action.  The  bulk  of  this  fluid  pours  down  into  the  vagina,  but  many  of 
the  cells  which  it  contains  pass  upwards  into  the  body  of  the  uterus,  and 
through  the  Fallopian  tubes  as  far  as  the  ovaries.  Should  they  come  in 
contact  with  an  ovule,  impregnation  may  take  place  in  the  ovaries,  Fallo- 
pian tubes,  or  uterus.  When  the  impregnated  ovule  attaches  itself  to  the 
uterus,  the  mucous  membrane  of  this  organ  undergoes  exuberant  develop- 
ment, and  throws  around  it  an  envelope  called  the  decidua  reflexa.  Fur- 
ther than  this,  the  process  does  not  concern  us,  for  conception  has  then 
followed  impregnation,  fixation  of  the  impregnated  ovum  having  occurred. 

These  facts  being  kept  in  mind,  it  becomes  evident  that  a  variety  of 
influences  may  interfere  with  the  performance  of  this  delicate  and  subtle 
process.  For  its  accomplishment  four  things  are  necessary  as  far  as  the 
woman  is  concerned. 

1st.  The  possibility  of  the  entrance  of  seminal  fluid  into  the  uterus  ; 

2d.    The  possibility  of  the  production  of  a  healthy  ovule  ; 

3d.    The  possibility  of  the  entrance  of  an  ovule  into  the  uterus  ; 

4th.  The  absence  of  influences  in  utero  destructive  to  the  vitality  of  the 
semen,  and  preventive  of  fixation  of  the  ovum  upon  the  uterine  wall. 

Should  these  four  conditions  exist,  no  woman  will  be  sterile.  She  may 
not  bear  children,  but  the  incapacity  may  attach  to  the  male  and  not  to 
her;  or,  having  conceived,  she  may  have  suffered  from  consecutive  abor- 
tions,  which  have  been  mistaken  for  attacks  of  menorrhagia. 


causes.  G49 

The  special  causes  of  sterility,  or  those  interfering  with  these  condi- 
tions, may  be  thus  presented  : — 

1st.    Causes  preventing  entrance  of  semen  into  the  uterus. 
Absence  of  the  uterus  or  vagina  ; 
Obturator  hymen  ; 
Vaginismus  ; 
Atresia  vagi  me  ; 
Occlusion  of  cervical  canal ; 
Conical  shape  of  cervix  ; 
Cervical  endometritis  ; 
Polypi  or  fibroids  ; 
Displacements  ; 

Very  small  os  internum  or  externum. 
2d.    Causes  preventing  the  production  of  a  healthy  ovule. 
Chronic  ovaritis  ; 
Cystic  disease  of  both  ovaries  ; 
Cellulitis  or  peritonitis  ; 
Absence  of  ovaries. 
3d.    Causes  preventing  passage  of  ovule  into  uterus. 
Stricture  or  obliteration  of  Fallopian  tubes  ; 
Absence  of  Fallopian  tubes; 

Detachments  and  displacements  of  Fallopian  tubes. 
4th.    Causes  destroying  vitality  of  semen  or  preventing  fixation  of  im- 
pregnated ovum. 
Corporeal  or  cervical  endometritis  ; 
Membranous  dysmenorrhea ; 
Menorrhagia  or  metrorrhagia ; 
Abnormal  growths  ; 
Areolar  hyperplasia. 
The  mode  of  action  of  most  of  these  causes  is  so  self-evident  as  to  make 
anything  more  than  their  mention  unnecessary.     Some  of  them,  however, 
require  special  explanation. 

Vaginismus  is  an  appellation  which  has  been  given  of  late  years  to  a 
hyperaesthetic  state  of  the  ostium  vaginae,  which  results  in  spasm  of  its 
sphincter.  This  interferes  with  the  entrance  of  the  male  organ,  and  con- 
sequently of  seminal  fluid  into  the  vaginal  canal ;  indeed,  in  aggravated 
cases,  it  entirely  precludes  sexual  approaches.  The  affection  is  by  no 
means  rare,  and  is  a  fruitful  source  of  sterility. 

An  abnormal  shape  of  the  cervix  has  been  pointed  out  by  Dr.  Sims  as 
a  frequent  cause  of  infecundity.  If  this  part  be  too  long,  so  as  to  curl  or 
bend  upon  itself,  it  is  evident  that  it  may  not  admit  seminal  fluid  through 
its  canal.  But  even  a  slighter  degree  of  elongation,  in  which  the  cervix 
has  a  conical  shape,  has  been  observed  to  be  frequently  followed  by  that 


650 


STERILITY. 


Fig.  250. 


Conoidal  cervix.     (Sims.) 


condition.     Fig.  250  represents  the  variety  of  conoidal  cervix  generally 
met  with  as  productive  of  sterility. 

Endometritis,  whether  it  he  cervical  or  corporeal,  fills  the  uterine  canal 
with  a  thick,  tenacious  mucus,  which  often  prevents  the  entrance  of  semi- 
nal fluid  or  destroys  its  vitality. 

Flexions  of  the  uterus,  hy  producing  bending  of  the  cervical  canal,  and 
versions,  by  pressing  the  os  against  one  wall  of 
the  vagina,  so  as  to  close  it  as  if  by  a  valve,  may 
entirely  obstruct  the  passage  to  the  uterus. 

Obliteration  and  displacement  of  the  tubes 
frequently  result  from  pelvic  peritonitis,  and 
thus  that  affection  often  entails  sterility  of  the 
most  irremediable  character.  The  second  stage 
of  the  disease  consists  in  effusion  of  lymph, 
which  in  time  undergoes  contraction,  and  either 
closes  these  canals  or  draws  them  out  of  place. 

Membranous    dysmenorrhoea,   or   rather   the 
tendency  to  exfoliation  of  uterine  mucous  mem- 
brane   which    characterizes    it,    so    alters    the 
uterine  surface  as  to  render  it  inapt  for  the  fixation  of  the  ovum. 

Menorrhagia  and  metrorrhagia  may  result  in  the  washing  away  of  the 
ovum  after  impregnation  and  before  fixation.  The  normal  menstrual 
hemorrhage  occurs  before  the  entrance  of  the  ovule  into  the  uterus.  If  it 
be  excessive  and  prolonged,  it  may  remove  the  ovule  entirely,  and  in  the 
same  way  metrorrhagia  may  remove  the  impregnated  ovum.  An  abortion 
does  not  occur  under  these  circumstances,  for  although  impregnation  may 
have  taken  place,  conception  has  not  done  so. 

Abnormal  growths  of  any  form  which  fill  the  uterine  cavity,  as,  for 
example,  fibroids,  polypi,  hydatids,  or  moles,  may  so  interfere  with  the 
attachment  of  the  ovum  to  the  uterus,  as  to  prevent  conception  even  when 
impregnation  has  occurred. 

Although  it  is  impossible  to  give  positive  proof  of  the  fact  that  serious 
chronic  disease  of  the  ovaries  results  in  a  blighting  influence  upon  the 
ovule,  such  a  conclusion  is  rendered  highly  probable  by  the  results  of  ex- 
perience in  such  cases.  Such  a  result  is  often  found  to  attend  chronic 
ovaritis,  general  pelvic  peritonitis  or  cellulitis,  and  double  cystic  disease. 

Some  of  the  causes  here  enumerated  are  much  more  frequent  than 
others.  I  would  enumerate  the  most  common  causes  in  the  order  of  their 
frequency  in  the  following  sequence.  First,  glandular  cervical  endome- 
tritis ;  second,  areolar  hyperplasia,  the  result  of  subinvolution  of  the  ute- 
rus ;  third,  conoid  cervix,  with  contracted  os  ;  fourth,  flexion  and  version 
of  the  uterus ;  fifth,  contraction  of  os  externum  ;  sixth,  fibroids,  intersti- 
tial, or  submucous;  seventh,  menorrhagia  or  metrorrhagia;  and  eighth, 
ovarian  incapacity  from  chronic  ovaritis  or  pelvic  peritonitis.     I  do  not 


TREATMENT.  651 

state  this  sequence  dogmatically,  but  merely  to  convey  an  idea  of  my  im- 
pressions with  reference  to  the  matter. 

Differentiation — Before  it  is  determined  that  a  woman  is  sterile,  the 
sexual  capacity  of  the  husbnnd  should  be  ascertained.  Men  are  averse  to 
the  confession  of  impotence,  and  will  often  allow  the  supposition  of  sterility 
on  the  part  of  their  wives  to  be  maintained  rather  than  admit  the  truth. 
In  two  cases  I  have  used  an  anaesthetic,  ruptured  the  hymen,  and  distended 
the  vagina,  under  the  impression  that  sterility  of  several  years'  standing 
was  due  to  the  impossibility  of  the  accomplishment  of  intercourse,  and 
have  subsequently  discovered  that  the  husbands  of  my  patients  were 
entirely  impotent,  and  had  been  so  before  marriage. 

Prognosis In  reference  to  a  disorder  wdiich  may  be  produced  by  such 

a  variety  of  causes,  no  positive  prognosis  can  be  given,  for  its  cure  will 
entirely  depend  upon  the  removal  of  the  agency  which  produces  it.  Much, 
too,  will  depend  upon  the  thorough  investigation  of  the  causes  by  the 
physician,  and  a  proper  understanding,  on  his  part,  of  the  treatment.  Un- 
questionably a  large  proportion  of  sterile  women  may,  by  appropriate 
treatment,  be  made  fruitful. 

Results. — No  physical  results  are  produced  by  sterility,  but  its  existence 
will  frequently  depress  the  spirits  and  sadden  a  disposition  which,  under 
other  circumstances,  would  have  been  cheerful  and  equable.  The  married 
woman  has  always  regarded  and  will  forever  view  this  incapacity  as  a 
reproach  to  her  womanhood,  and  no  amount  of  argument  can  make  her 
accept  it  with  resignation. 

Treatment The  treatment  of  sterility  consists  in  the  removal  of  its 

cause.  Many  of  these  causes  are  not  susceptible  of  remedy,  while  the  means 
of  treating  others  are  so  evident  that  special  mention  maybe  confined  to  a 
few.  Obturator  hymen,  vaginismus,  atresia  vaginaa,  and  occlusion  of  the 
cervical  canal  should  be  treated  by  the  surgical  operations  appropriate  to 
each. 

In  case  the  vaginal  cervix  should,  to  only  a  limited  extent,  be  too  pro- 
jecting or  conical,  the  bilateral  operation  for  its  enlargement  should  be 
practised  after  the  method  elsewhere  described.  If  a  slight  constriction 
of  the  cervical  canal  appear  to  be  the  cause  of  the  condition,  dilatation 
may  be  essayed  in  place  of  a  surgical  procedure.  In  an  aggravated  case, 
when  the  neck  projects  markedly  and  is  decidedly  conoidal  in  shape,  both 
these  means  are  insufficient ;  amputation  then  becomes  necessary.  After 
this  has  been  recovered  from,  the  bilateral  operation  for  cervical  hyste- 
rotomy is  often  necessary  before  cure  is  effected.  In  this  connection  the 
chapters  upon  dysmenorrhcea  and  amputation  of  the  cervix  should  be 
referred  to.  Endometritis  should  be  appropriately  treated,  and  abnormal 
growths  should  be  dealt  with  as  if  sterility  did  not  exist. 

If  a  displacement  be  discovered  and  replacement  and  retention  be  pos- 
sible, they  should  be  practised.     But  if  in  case  of  flexion  this  be  impos- 


652      AMPUTATION  OF  THE  NECK  OF  THE  UTERUS. 

sible,  the  uterine  canal  should  be  rendered  as  straight  as  is  practicable,  by 
the  cervical  incision  recommended  by  Dr.  Sims  for  dysmenorrhcea.  Men- 
orrhagia and  metrorrhagia  should  be  treated  upon  the  plan  recommended 
in  the  chapter  upon  those  subjects,  and  the  patient  be  advised  to  keep  very 
quiet  and  to  avoid  warm  and  stimulating  beverages  during  menstrual 
epochs. 

A  remark  made  in  connection  with  the  treatment  of  leucorrhcea  may 
with  propriety  be  repeated  here,  namely,  that  to  enter  more  minutely  into 
the  study  of  special  remedial  measures  would  tend  to  divert  the  mind  of 
the  reader  from  a  point  which  I  regard  as  of  paramount  importance  ;  that 
this  affection  is  commonly  only  a  symptom  which  should  be  reached 
through  the  malady  which  induces  it. 

As  I  have  elsewhere  stated,  glandular  endometritis  and  tortuosities  of 
the  uterine  neck  are  among  the  most  frequent  of  the  causes  of  sterility. 
The  first  of  these  is  a  disorder  which  is  often  incurable,  and  the  surgical 
operations  practised  for  the  latter  very  commonly  fail  of  result.  And  so 
with  regard  to  other  conditions  resulting  in  sterility.  If  at  the  end  of 
a  large  experience  every  one  would  compare  the  number  of  his  failures 
in  treating  sterility  with  that  of  his  successes,  his  results  would  not  be 
regarded  as  very  satisfactory.  Unfortunately,  the  unsuccessful  cases  soon 
sink  beneath  the  mental  horizon,  while  the  successful  ones  stand  out  promi- 
nently, and  thus  many  a  practitioner,  by  his  evidence,  unintentionally 
misleads  others  and  produces  disappointment. 


CHAPTER    XLV. 

AMPUTATION  OF  THE  NECK  OF  THE  UTERUS. 

Althougu  the  recognition  of  the  important  role  played  by  laceration 
of  the  cervix  in  uterine  pathology  will  certainly  circumscribe  very  much 
the  field  of  this  operation,  there  are  nevertheless  conditions  which  will  still 
call  for  a  resort  to  it  as  the  most  effective  surgical  resource.  As  a  full 
description  of  the  operation  has  not  yet  been  elicited  by  previous  chapters 
of  this  work,  it  will  be  well  to  consider  it  here  before  leaving  the  con- 
sideration of  uterine  and  taking  up  that  of  ovarian  diseases. 

History Ambrose  Pare1  was  the  first  surgeon  who  advised  amputation 

of  the  cervix.  He  recommended  it  in  malignant  growths  of  the  part,  to 
which,  he  says,  "  we  may  apply  the  speculum  matricis,  in  order  to  see 
more  easily."  It  is  reported,  upon  insufficient  authority,  to  have  been 
performed  as  early  as  16.52,  by  Tulpius,  of  Amsterdam,  and  in  17G6,  by 

'  ffiuvres  d'Ambroise  Par6,  lib.  xxiv.  p.  1012. 


CONDITIONS    DEMANDING    AMPUTATION.  653 

La  Peyronie.  Daniel  Turner,1  of  London,  in  173G,  reported  an  instance 
in  which  the  neck  of  a  prolapsed  uterus  was  amputated  by  means  of  a 
razor  in  the  hands  of  the  patient  herself,  who  was  insane.  The  recovery 
of  the  woman  was  evidently  regarded  as  a  wonderful  circumstance.  In 
1M02,  the  operation  was  systematized  by  Osiander,  who  performed  it 
twenty-three  times,  and  after  this  it  was  resorted  to  by  Dupuytren,  Reca- 
mier,  Ilervez  de  Chegoin,  and  others.  It  was,  however,  in  the  hands  of 
Lisfranc  that  it  attracted  special  attention,  and  in  consequence  of  his  en- 
thusiasm it  was  for  a  time  regarded  as  a  means  which  was  destined  to 
accomplish  a  vast  deal  of  good.  His  reports  of  its  results  were  most 
favorable,  and  he  described  its  dangers  as  slight.  But  soon  after  his  pub- 
lications upon  it  there  appeared  a  counter-report  from  the  young  physician2 
who  took  charge  of  many  of  his  cases  and  was  familiar  with  all,  which 
cast  discredit  upon  all  the  master's  statements.  By  Pauly,  the  truth  was, 
as  Becquerel  expresses  it,  "  brutally  revealed,"  and  it  was  entirely  at  va- 
riance with  the  representations  of  Lisfranc.  Since  that  time  the  operation 
has  to  a  certain  extent  fallen  into  disrepute,  but  is  still  resorted  to  in  appro- 
priate cases. 

Dangers The  dangers  of  the  procedure  are  the  following  : — 

Primary  hemorrhage  ; 
Secondary  hemorrhage  ; 
Peritonitis  ; 
Cellulitis  ; 
Tetanus. 
The  statistics  of  the  operation  have  not  as  yet  been  carefully  collected. 
Lisfranc  reported  99  operations  and  only  two  deaths,  but  these  statements 
Pauly  renders  more  than  doubtful.     Iluguier  reports  13  operations  and  no 
deaths  ;  Sims  over  50  operations   and  one  death  ;  and  Simpson  8  opera- 
tions and  one  death. 

Even  these  reports,  favorable  as  they  are,  refer  to  the  results  of  ampu- 
tation by  the  knife.  By  galvano-cautery  much  better  results  are  obtained. 
It  is  really  surprising  to  see  how  little  constitutional  disturbance  follows 
this  operation.  Out  of  the  large  experience  of  Dr.  Byrne,  of  Brooklyn, 
with  it,  no  fatal  case  is  reported;  and  only  one  bad  result  has  occurred  in 
my  own  practice  in  over  fifty  amputations  oi'  the  whole  cervix. 

Conditions  demanding  Amputation The   conditions   which  ordinarily 

call  for  removal  of  the  cervix  are  the  following: — 
Malignant  disease  ; 

Great  enlargement  from  cervical  hyperplasia  ; 
Longitudinal  cervical  hypertrophy  ; 
Conical  and  projecting  cervix  ; 
Granular  or  cystic  degeneration  of  intractable  character. 

1  New  York  Med,  Journ.,  vol.  v.  No.  5. 

2  Pauly,  Maladies  de  P Uterus,  Paris,  1836. 


654      AMPUTATION  OF  THE  NECK  OF  THE  UTERUS. 

One  of  these  conditions,  longitudinal  cervical  hypertrophy,  not  having 
previously  received  special  mention,  requires  it  here.  The  cervix  may  be 
congenitally  very  much  elongated  below  the  vaginal  junction.  Generally 
it  undergoes  hypertrophic  elongation  from  a  simple  formative  irritation,  a 
low  grade  of  cervical  endometritis,  congestion  long  kept  up,  or  prolapsus 
in  the  third  degree.  Under  these  circumstances  the  neck  grows  very  long, 
so  as  to  rest  between  the  labia  or  even  to  project  for  a  number  of  inches 
from  the  body,  and  it  has  in  some  instances  been  mistaken  for  the  penis.  By 
means  of  the  touch,  conjoined  manipulation,  the  speculum,  and  the  probe, 
a  diagnosis  can  readily  be  made.  M.  Iluguier,  some  years  ago,  maintained 
that  this  condition  often  deceived  practitioners  into  the  belief  in  prolapsus 
uteri. 

Varieties  of  the  Operation — In  some  cases,  as  in  cancer,  for  example, 
it  is  necessary  to  remove  the  entire  cervix  and  even  as  much  tissue  as 
possible  from  that  portion  of  the  organ  above  the  vaginal  attachment.  In 
others,  only  half  of  the  vaginal  portion  requires  ablation,  while  in  still 
another  set  of  cases,  only  the  removal  of  a  thin  section  of  the  hypertro- 
phied  lips  is  called  for. 

Methods  of  Performance. — The  operation  may  be  performed  by  the 
following  methods : — 

By  the  bistoury  or  scissors  ; 

By  the  ecraseur ; 

By  the  galvano-caustic  battery. 

Operation  by  Bistoury  or   Scissors When   performed   by  the   first 

method,  the  patient  should  be  placed  upon  the  left  side  and  Sims's  specu- 
lum employed.  The  cervix  being  slit  bilaterally,  one  lip  is  seized  and  cut 
off  as  near  the  vaginal  junction  as  is  deemed  advisable,  and  then  the  other 
is  removed  in  a  similar  manner.  Formerly  the  operation  was  completed 
at  this  point,  but  Dr.  Sims  has  introduced  the  practice  of  drawing  down 
the  mucous  membrane  and  stitching  it,  with  silver  sutures,  so  as  to  cover 
the  stump,  as  that  of  the  arm  or  thigh  is  covered  by  skin  after  amputation 
of  those  parts.  When  the  stump  is  covered  by  mucous  membrane,  after 
this  plan,  recovery  is  much  more  rapid  than  when  granulation  is  allowed 
to  accomplish  the  cure.     This  operation  is  often  a  bloody  one. 

Operation  by  the  Ecraseur. — In  operating  by  this  method,  if  the  uterus 
be  prolapsed,  if  the  degree  of  longitudinal  hypertrophy  be  so  excessive 
as  to  cause  full  protrusion  of  the  cervix,  or  if  such  protrusion  be  attain- 
able by  moderate  traction,  the  patient  may  be  placed  on  the  back.  If  the 
uterus  be  high  up  in  the  pelvis  and  strong  traction  be  necessary  to  depress 
it,  the  best  position  will  be  found  to  be  that  advised  when  scissors  or  the 
bistoury  are  employed,  the  speculum  being  used.  The  passage  of  the 
chain  will  be  found  to  be  very  simple,  and  the  part  should  be  slowly  cut 
through. 

In  using  the  ecraseur  for  this  purpose,  great  care  should  be  observed 


METHODS    OF    PERFORMANCE. 


G55 


not  to  allow  of  too  great  dragging  of  the  chain  upon  the  neck  without 
cutting.  If  attention  he  not  given  to  this  point,  the  peritoneum  may  he 
opened  or  the  bladder  involved. 

I  describe  the  operation  by  the  ecraseur,  although  I  regard  it  as  inferior 
in  merit  to  both  the  other  methods  mentioned.  I  do  this  because  the  ope- 
ration is  often  called  for  far  from  surgical  centres,  where  it  is  very  difficult 
to  procure  a  battery,  and  where  no  operator  of  sufficient  skill  can  be  found 
to  perform  amputation  by  cutting  instruments. 

Operation  by  G ' alvano-cautery The  galvano-caustic  apparatus  consists 

simply  of  an  instrument  which  enables  the  operator  to  engage  any  part  in 
a  loop  of  wire  which,  being  connected  with  a  powerful  galvanic  battery, 
becomes  red  hot  and  cuts  its   way  through.     The  instruments  generally 


Fig.  251. 


Byrne's  galvano-caustic  battery.1 

employed  here  are  a  German  battery,  Middledorpf's;  or  Grennett's,  a  very 
compact  instrument  made  in  London  ;  and  one  constructed  by  W.  F.  Ford, 

'  For  details  concerning  this  instrument  I  refer  the  reader  to  Dr.  Byrne's  inter- 
esting brochure  entitled  Electro-cautery  in  Uterine  Surgery,  Wm.  Wood  &  Co. 


656  DISEASES    OF    THE    OVARIES. 

of  New  York,  after  a  method  suggested  by  Dr.  Jolin  Byrne.  It  would 
be  out  of  place  here  to  give  details  concerning  these  instruments  ;  all  of 
them  answer  the  purpose  in  view  very  well.  That  of  Dr.  Byrne  is,  for 
an  American,  most  attainable,  and  is  certainly  a  very  efficient  and  reliable 
apparatus.     It  is  shown  in  Fig.  251. 

In  amputating  the  neck  in  this  May,  the  patient  may  be  placed  upon 
the  back,  and  the  uterus  drawn  down  between  the  labia ;  or,  if  this  de- 
pression of  it  be  difficult,  she  may  be  placed  upon  the  side,  and  Sims's 
speculum  employed.  By  one  of  these  procedures  the  part  to  be  ampu- 
tated is  fairly  exposed  to  view  and  manipulation.  The  wire  loop  of  the 
galvano-cautery  is  passed  around  the  neck  as  high  up  as  is  deemed  safe, 
and  tightened  until  it  is  fixed  in  the  tissues  so  as  not  to  slip.  Then  the 
current  of  electricity  is  made  to  pass  through  it,  and  the  loop  being  slowly 
tightened  by  the  turning  of  a  screw  by  the  operator  the  cervix  is  ampu- 
tated. 

Sometimes  the  removal  of  the  portion  of  the  cervix  desired  is  difficult  of 
attainment,  a  scalping  process  being  substituted  for  a  complete  amputation. 
To  accomplish  the  operation  completely,  I  have  devised  the  forceps  shown 
in  Fig.  235.  By  the  long,  sliding  screw  between  the  blades,  the  cervix 
is  drawn  into  their  grasp  and  fixed  by  closing  them.  Then  the  screw  is 
withdrawn,  and  the  cold  wire  slid  over  the  projecting  portions  and  tight- 
ened, and,  the  electric  current  passing,  a  red,  and  not  a  white,  heat  being 
established,  the  cervix  is  completely  removed. 

By  this  method  immediate  hemorrhage  is  usually  controlled,  but  not  so 
remote  hemorrhage.  Sometimes  on  the  fifth,  sixth,  or  even  the  tenth 
day  a  most  active  How  takes  place  in  spite  of  every  precaution.  For  this 
reason  the  tampon  should  be  used  after  such  an  amputation,  and  the 
patient's  convalescence  be  carefully  watehed. 


CHAPTER    XLVI. 

DISEASES  OF  THE  OVARIES. 

History. — Ancient  literature  is  singularly  barren  upon  the  subject  of 
ovarian  diseases.  That  the  functions  of  these  organs  were  known  to  early 
anatomists,  there  is  no  doubt,  for  as  early  as  200  B.  C.  the  operation  of 
castration  of  female  animals  is  alluded  to  by  Aristotle,  and  in  the  second 
century  A.  C.  they  were  described  by  Galen  under  the  name  of  "testes 
muliebres."  As  to  the  influence  exerted  by  them  upon  menstruation, 
they  were  not  informed,  for  they  attributed  that  process,  according  to 
Aristotle,  to  a  superfluity  in  the  blood,  an  opinion  which  was  entertained 


HISTORY.  657 

even  by  Hippocrates.  The  works  of  Aetius  make  no  mention  whatever 
of  ovarian  disorders,  and  those  of  Paul  of  JEgina  are  equally  silent.  When 
it  is  borne  in  mind  that  the  ovular  theory  of  menstruation  dates  back  for 
its  origin  to  the  labors  of  Negrier,  Gendrin,  Bischoff,  Pouchet,  and  others  of 
our  own  time,  and  that  the  operation  of  ovariotomy  was  never  systemati- 
cally performed  before  the  year  1809,  it  will  be  appreciated  how  recently 
the  profession  even  in  modern  times  has  fully  grappled  with  the  subject. 

During  the  past  twenty  years  full  amends  have  been  made  for  this 
delay  in  progress,  for  in  that  time  no  portion  of  the  field  of  gynecology 
has  received  more  attention  or  been  more  thoroughly  investigated  than 
that  which  now  engages  us.  Not  only  have  most  of  the  diseased  condi- 
tions of  the  ovaries  been  satisfactorily  investigated,  and  the  diagnosis  of 
tfiem  reduced  to  a  scientific  system ;  for  the  most  frequent  and  important 
of  them  surgical  means  have  been  instituted  with  such  success  as  to  have 
given  procedures  of  the  most  appalling  character  and  undoubted  dangers 
the  position  of  legitimate  and  justifiable  operations.  The  recent  literature 
of  ovarian  pathology  and  surgery  is  now  enriched  by  the  contributions  of 
so  many  capable  observers,  that  it  is  almost  invidious  to  particularize  the 
most  prominent.  Unfortunately  there  is  one  set  of  ovarian  affections  with 
reference  to  which  these  statements  are  not  true  ;  those  of  inflammatory 
character.  Our  means  of  diagnosis  of  ovaritis,  both  acute  and  chronic,  is, 
in  spite  of  all  the  advances  alluded  to,  so  elementary  and  unreliable  that 
the  result  is  discordance  of  views,  and  uncertainty  as  to  pathology  and 
therapeutics.  It  was  probably  the  contemplation  of  this  fact  which  led 
Scanzoni  to  open  his  article  upon  diseases  of  the  ovaries  with  the  following 
sentence :  "  If  we  felicitate  ourselves  upon  the  progress  which  has  been 
made  during  the  last  few  years,  in  the  diagnosis  and  treatment  of  the 
diseases  of  the  uterus,  we  should,  on  the  other  hand,  remember  that  the 
labors  of  gynecologists  in  respect  to  the  diseases  of  the  ovaries  have  been 
almost  fruitless  in  practical  results." 

In  illustration  of  the  difficulties  attending  the  diagnosis  of  ovarian 
diseases,  I  introduce  a  table  which  I  have  constructed  from  Henna's1 
report  of  one  hundred  post-mortem  examinations  made  by  him,  with  spe- 
cial reference  to  this  point.  "If  we  now  turn  our  attention,"  says  he, 
"  to  the  diseases  of  the  ovaries,  it  is  a  fact  of  great  value,  in  reference  to 
diagnosis,  that  in  ten  out  of  one  hundred  cases,  the  diseased  state  of  the 
ovary  was,  or  might  have  been,  recognized  during  life — more  frequently 
by  rectal  exploration  than  by  vaginal  or  abdominal."  On  the  other  hand, 
out  of  81  bodies,  a  diseased  condition  of  the  ovaries  was  found  in  53,  a 
proof  of  how  frequently  disease  of  the  ovaries  cannot  be  recognized  during 
life.  The  diseased  condition  was  more  frequent  in  one  ovary  alone  than 
in  both ;  this  being  found  in  three-fourths  of  the  cases. 

1  Catarrh  of  Sexual  Organs  of  the  Female.     By  Carl  Hennig. 
42 


658 


DISEASES    OF    THE    OVARIES. 


*  • 

-  c 

A 

E*s 

—  s. 

as  c 

» 

o2 

Iff 

e.  a 

a 
o 

*  b 

-Z  a) 

0  > 

2 
o 

is 

c'-3 

>> 

£* 

►.«- 

K  o 

a> 

•O  60 

55 

o 

u 

EC 

W 

E 

fi 

s 

53 

(«                   II              11 

30 

<<                         CI                  (1 

5 

<(                  II             II 

1 

II                  II             II 

6 

It                  II             II 

9 

II                   II              II 

1 

II                  II             II 

1 

Anatomy  of  the  Ovaries The  ovaries  are  two  follicular  glands  about 

the  shape  and  size  of  small  almonds,  situated  one  on  each  side  of  the 
uterus.  So  dej>endent  are  they  upon  the  position  of  the  uterus  and  sur- 
rounding viscera  that  they  have  really  no  fixed  place.  They  are  usually 
found  in  the  lateral  and  posterior  parts  of  the  true  pelvis,  about  an  inch 
from  the  uterus,  and  just  below  the  point  where  the  Fallopian  tubes  enter 
that  organ,  the  left  being  in  close  proximity  with  the  rectum.  Each 
ovary  is  attached  to  the  peritoneum,  which  connects  it  with  adjacent 
structures,  and  is  firmly  united  with  the  uterus  by  means  of  a  fibrous  cord 
arising  from  the  horn  of  each  side. 

The  Fallopian  tube  of  each  side  is  connected  with  the  ovary  by  one 
fimbria,  and  acts  at  periods  of  ovulation  as  its  excretory  duct.  The  sur- 
face of  the  ovary  is  not  covered  by  peritoneum,  for,  arrived  at  the  circum- 
ference of  these  organs,  this  membrane  loses  its  characteristic  appearances, 
and  the  only  trace  of  it  which  is  discoverable  is  a  layer  of  basement- 
epithelium.1  Around  the  circumference  of  the  ovaries  a  cortical  portion 
exists,  whose  duty  it  is  to  generate  the  Graafian  follicles.  Within  this  is 
a  fibrous  structure,  composed  of  muscular  fibres,  cellular  tissue,  vessels, 
and  nerves,  which  receives  the  name  of  stroma.  Removed  from  the 
stroma  and  examined  with  care  by  the  microscope,  each  of  the  Graafian 
vesicles  is  found  to  consist  of  a  sac,  called  the  tunic,  which  is  filled  with 
fluid,  the  liquor  folliculi,  in  which  is  contained  the  ovum  or  egg  which  is 
the  female  contribution  to  conception. 

It  is  now  accepted  as  a  fact  by  most  physiologists,  although  still  con- 
tested by  some,  that  the  periodical  discharge  of  blood  from  the  uterus, 
which  is  called  menstruation,  is  merely  a  uterine  symptom  of  the  discharge 
of  one  of  the  ova  from  the  ovary  by  rupture  of  a  follicle.  After  the  period 
of  puberty  has  arrived,  one  or  more  of  the  follicles  of  each  ovary  burst 
every  month  by  the  following  process :  a  congestion  or  hyperemia  occur- 


1  For  details  with  regard  to  these  curious  and  recently  discovered  facts,  the 
reader  is  referred  to  essays  by  Otto  Schrone,  Henle,  and  Sappey. 


ANATOMY    OF    THE    OVARIES.  059 

ring  in  the  ovary  for  some  reason  beyond  our  comprehension,  causes  an 
excessive  secretion  by  the  walls  of  the  follicle,  in  which  a  miniature 
dropsy  takes  place.  This  goes  on  to  rupture,  and  escape  of  the  liquor 
folliculi,  blood,  granular  cells  lining  the  ovisac,  and  the  ovum.  The 
nerve  supply  to  both  uterus  and  ovaries  is  excited  by  this  process,  and 
one  of  the  results  of  such  excitement  is  contraction  of  the  delicate  middle 
layer  of  uterine  fibres  which  surround  the  network  of  minute  vessels  en- 
veloping and  penetrating  the  uterine  structure.  This  throws  the  vascular 
apparatus  into  a  state  of  erection.  Great  engorgement  occurs  on  the  sur- 
face of  the  uterine  mucous  membrane,  and  probably  on  that  lining  the 
Fallopian  tubes;  they  rupture,  and  a  flow  of  blood  takes  place.  Three 
elements  are  concerned  in  this  discharge:  1st,  ovarian  irritation  excited 
by  ovulation  and  transmitted  to  the  nerves  governing  the  muscles  consti- 
tuting the  middle  coat  of  uterine  fibres;  2d,  erection  of  the  uterine  vascu- 
lar system;  3d,  consequent  rupture  of  the  bloodvessels  of  the  mucous 
membrane  of  the  uterus  and  escape  of  blood.  The  ovisac  being  thus 
emptied,  a  clot  of  blood  soon  forms  within  it,  then  an  hypertrophy  of  the 
cells  lining  it  occurs,  and  the  corpus  luteum  is  formed. 

If  the  examiner  hold  up  one  of  the  broad  ligaments  between  himself  and 
the  light,  a  small  plexus  of  white,  crooked  tubes  will  be  seen  forming  a 
cone,  the  apex  of  which  is  directed  towards  the  hilus  of  the  ovary.  It 
measures  about  an  inch  in  breadth,  and  consists  of  about  twenty  tubes 
which  are  filled  with  a  clear  fluid.  This  is  the  organ  of  Rosenmuller, 
which  has  recently  been  minutely  described  by  Kobelt  under  the  name  of 
the  par-ovarium,  and  is  supposed  by  him  to  be  an  exaggeration  of  the 
Wolffian  body.  The  exact  location  of  the  par-ovaria  is  this  :  they  lie  be- 
neath the  ovaries  and  between  the  ultimate  folds  of  the  peritoneum  cover- 
ing the  fimbriated  extremities  of  the  Fallopian  tubes,  which  have  received 
the  name  of  the  alas  vespertilionum. 

The  ovaries  are  supplied  with  blood  through  the  spermatic  arteries, 
which,  upon  arriving  at  the  margin  of  the  pelvis,  pass  inwards  between 
the  layers  of  the  broad  ligaments,  and  thus  reach  their  lower  border.  Their 
nervous  supply  is  not  extensive,  and  is  derived  from  the  renal  plexus. 

The  ovary  presents  its  most  perfect  type  in  the  young  virgin,  when  its 
dimensions  are  greatest  and  its  surface  undeformed  by  the  numerous  cica- 
trices which  appear  at  a  later  period.  The  dimensions  of  this  organ  are 
greater  than  they  are  during  early  virgin  life  only  during  and  for  six 
weeks  after  the  process  of  utero-gestation.  Hennig,  who  has  made  a  spe- 
cial and  exceedingly  minute  study  of  this  point,  declares  that  pregnancy 
increases  the  length  but  not  the  breadth  nor  the  thickness  of  the  organ. 
Utero-gestation,  which  leaves  the  uterus  larger  than  it  was  before,  has  the 
contrary  effect  upon  the  ovaries,  which  after  its  accomplishment  diminish 
in  size,  never  again  to  attain  their  former  dimensions  while  in  a  state  of 
health. 


660  DISEASES    OF    THE    OVARIES. 

Varieties  of  Ovarian  Disease Any  one  or  all  of  the  tissues  which 

have  been  mentioned  may  be  affected  by  disease,  or  the  position  of  the 
ovary  may  be  altered  to  such  an  extent  as  to  constitute  a  morbid  state. 
The  following  table  presents  a  list  of  the  disorders  of  these  glands  which 
will  now  receive  special  attention  : — 

Absence ; 

Imperfect  development ; 

Atrophy ; 

Inflammation  ; 

Neoplasms. 

Absence. 

One  or  both  of  the  ovaries  may  be  congenially  absent,  but  such  a  con- 
dition is  very  rare.  When  it  does  exist,  it  is  generally  only  a  part  of  a 
complete  want  of  genital  development  which  is  manifested  not  only  bv 
these  organs  but  by  the  parts  making  up  the  vulva,  the  vagina,  and  the 
uterus.  Kiwisch  declares  that  it  has  been  most  frequently  observed  in  the 
bodies  of  newly-born  infants  who  were  not  viable  on  account  of  compli- 
cated deformities.  Where  there  is  congenital  absence  of  the  ovaries  the 
woman  is  generally  small  in  stature,  her  figure  undeveloped,  as  if  the 
period  of  girlhood  were  abnormally  prolonged,  and  the  genital  system  im- 
perfect, as  already  mentioned.  In  some  cases  the  mind  is  very  deficient, 
a  condition  bordering  upon  idiocy  sometimes  existing.  In  others  this  is 
not  the  case,  but  the  patient  suffers  from  depression  of  spirits,  and  appears 
to  lack  vigor  both  of  mind  and  body.  Development  into  womanhood  has 
never  arrived  for  her,  and  she  remains  a  child  without  the  vivacity  and 
cheerfulness  of  childhood. 

Although  certainty  can  only  be  arrived  at  post  mortem,  a  diagnosis  mry 
be  made  during  life  by  the  use  of  Simon's  method,  which  may  guide  us  in 
prognosis  and  treatment.  Indeed,  one  of  the  greatest  benefits  which  can 
accrue  from  a  correct  conclusion  will  consist  in  the  avoidance  of  all  efforts 
which,  being  vainly  addressed  to  exciting  the  performance  of  the  functions 
of  the  ovaries,  deteriorate  the  state  of  the  patient.  Should  the  general 
condition  of  the  patient,  the  undeveloped  state  of  the  vulva,  vagina,  and 
uterus,  and  the  entire  absence  of  the  menstrual  crisis  combine  as  evidences 
of  the  condition,  a  diagnosis  is  admissible. 

Imperfect  Development. 

This  condition,  which  consists  in  persistence  of  the  foetal  state  of  these 
organs  after  the  period  of  puberty  when  rapid  development  should  have 
occurred,  is  by  no  means  so  rare  as  that  just  mentioned.  It  may  exist  on 
one  side  only,  though  it  generally  affects  both.  As  in  the  case  of  absence 
of  the  ovaries,  a  certain  conclusion  is  not  e.osy,  and  as  in  that  case,  also, 
we  draw  a  presumptive  conclusion  from  want  of  development  in  the  other 


IMPERFECT    DEVELOPMENT.  Gb'l 

organs  of  generation,  absence  of  the  usual  signs  of  the  menstrual  crisis, 
and  lack  of  general  constitutional  vigor  and  development. 

As  examples  of  cases  susceptible  of  such  an  explanation,  I  record  the 
histories  of  two  with  which  I  have  recently  met.  The  first  is  that  ot' 
Miss  F.,  referred  to  me  by  Dr.  Kodenstein,  of  Manhattanville.  She  is 
twenty-lour  years  of  age,  and  yet  has  the  appearance  of  a  girl  of  thirteen. 
Indeed,  it  is  difficult  to  believe  the  statement  that  she  is  more  than  that 
age.  The  features,  limbs,  mode  of  expression,  and  general  deportment 
are  those  of  a  child.  She  has  never  menstruated  nor  shown  any  evidences 
of  a  tendency  to  do  so.  Physical  exploration  shows  the  vulva  in  the 
state  of  early  girlhood,  the  mons  veneris  destitute  of  hair,  the  labia  thin, 
and  the  vagina  so  small  and  narrow  that  the  little  finger  only  can  be  in- 
troduced, and  that  causes  great  suffering.  The  canal  being  short  as  well 
as  narrow,  the  uterus  can  be  touched,  and  is  found  like  a  little  nut  in  the 
vagina,  so  light  that  its  weight  is  scarcely  perceptible. 

The  second  case  is  one  which  I  saw  with  Prof.  W.  H.  Thompson.  The 
patient  is  eighteen  years  old,  and  has  never  menstruated.  Previous  to 
the  treatment  established  by  Dr.  Thompson,  she  suffered  greatly  from 
epileptic  seizures,  which  have  evidently  impaired  the  force  of  her  intellect, 
but  during  the  two  months  before  I  saw  her  she  had  been  free  from  them. 
The  girl  is  slow  in  her  movements,  childish  in  manner,  and  stupid  in  reply- 
ing to  questions.  Upon  physical  exploration,  the  vulva,  vagina,  and  uterus 
are  found  fully  and  perfectly  developed,  the  latter  giving  by  measurement, 
with  the  uterine  probe,  two  and  a  half  inches.  Nothing  can  be  elicited 
with  reference  to  the  ovaries  by  physical  means,  but  the  rational  signs 
mentioned,  together  with  the  fact  that  all  the  appearances  of  girlhood  are 
combined  with  entire  absence  of  any  apparent  effort  at  ovulation,  render 
the  supposition  that  the  ovaries  are  undeveloped,  or  foetal,  highly  probable. 

Sometimes  cases  will  be  met  with  in  which  masculine  development, 
emansio-mensium,  and  sterility  will  lead  to  a  diagnosis  of  absence  of  the 
ovaries,  but  which  will  subsequently  undergo  a  change  and  give  all  the 
evidences  of  the  presence  and  efficiency  of  these  organs.  One  such  case, 
which  occurred  in  the  practice  of  Dr.  Metcalfe  and  myself,  is  worthy  of 
record.  Mrs.  B.,  a  large,  muscular,  and  handsome  woman,  had  men- 
struated very  irregularly  and  scantily  for  ten  or  fifteen  years.  Sometimes 
the  menstrual  discharge  would  be  entirely  absent  for  months,  then  it  would 
at  long  and  irregular  intervals  show  itself  for  a  day.  Her  health  was  not 
affected  by  this  in  any  way.  She  presented,  however,  many  signs  of 
masculinity ;  the  voice  was  harsh,  the  breasts  flat,  and  the  chin  covered 
with  a  sparse  beard.  After  having  been  married  for  years  she  became 
pregnant,  and  in  due  time  bore  a  child,  subsequent  to  which  she  men- 
struated more  regularly  and  plentifully,  and  has  since  borne  two  children. 

Treatment. — Should  the  ovaries  be  congenitally  absent,  it  is  evident 
that  art   can   do  nothing  to  remedy  the   evil.     Should   they  exist  in  an 


662  DISEASES    OF    THE    OVARIES. 

undeveloped  or  foetal  state,  it  is  possible  that,  by  a  proper  stimulus  applied 
to  them  by  the  most  direct  means  in  our  power,  growth  and  maturity  may 
be  fostered,  unless  the  condition  be  one  of  aggravated  arrest  of  develop- 
ment.    The  means  which  are  most  likely  to  accomplish  this  are — 

General  tonics  ; 
Uterine  irritation  ; 
Electricity ; 
Marriage. 

The  sanguineous  and  nervous  systems  should  both  be  brought  into  as 
perfect  a  state  of  health  as  possible  by  ferruginous  and  bitter  tonics,  fresh 
air,  exercise,  change  of  scene,  and  a  general  observance  of  the  laws  of 
hygiene. 

The  most  direct  method  for  irritating  the  ovaries  is  through  the  uterus, 
with  which  so  close  a  sympathy  exists.  For  this  purpose  tents  may  be 
occasionally  resorted  to,  as  often,  for  instance,  as  once  or  twice  a  month. 
This  not  only  prepares  the  uterus  for  its  part  of  the  process  of  menstrua- 
tion, but  causes  a  hypenemia  in  the  ovaries,  which  we  know  to  be  the 
physiological  forerunner  of  ovulation. 

Electricity  may  be  employed  by  placing  one  pole  of  a  battery  over  the 
spine  and  one  over  the  ovaries,  or,  more  effectually,  by  carrying  one  pole, 
protected  where  it  touches  the  vagina,  to  the  cervix  uteri,  connecting  this 
with  a  battery,  and  passing  the  other  pole  over  the  ovaries.  An  intra- 
uterine galvanic  pessary  may  likewise  answer  a  good  purpose,  when  worn 
steadily  and  persistently. 

The  ovarian  irritation  and  congestion  incident  to  the  marital  act  will 
sometimes  excite  ovulation,  not  at  the  moment  of  coition,  as  was  formerly 
supposed,  but  remotely. 

Atrophy  of  the  Ovaries. 

At  a  period,  varying  from  the  fortieth  to  the  fiftieth  year,  the  ovaries 
are  destined  to  undergo  atrophy.  They  diminish  in  volume,  become 
wrinkled,  the  Graafian  follicles  disappear,  and  the  stroma  becomes  dense 
and  non-vascular.  This  is  a  physiological  process,  and  marks  what  is 
termed  the  menopause,  or  period  of  menstrual  cessation.  Sometimes  this 
process  sets  in  at  a  very  early  period,  owing  to  some  abnormal  condition 
which  has  excited  it,  and  produces  the  same  results  as  those  following  it 
when  it  takes  place  at  the  normal  time. 

Causes With  regard  to  the  special  causes  of  this  occurrence  very  little 

is  absolutely  known,  further  than  the  fact  that  it  sometimes  occurs  from 
pelvic  inflammations.  It  is  probable  that  acute  ovaritis  may  produce  it, 
and  it  is  certain  that,  at  times,  it  results  from  pelvic  peritonitis  and  cellu- 
litis. 

The  following  case  which  presented  itself  at  my  clinique  some  time  ago 
is  illustrative  of  this  fact.     Mary  G.,  a  healthy  young  Irish  woman,  aged 


OVARIAN    APOPLEXY.  G63 

24  years,  stated  that  she  had  a  miscarriage  at  the  third  menstrual  period, 
five  years  before,  in  Albany.  Three  days  after  the  product  of  conception 
had  been  cast  otf,  she  was  taken  with  a  chill,  with  violent  pain  over  the 
abdomen,  and  was  declared  by  her  physician  to  have  inflammation  of  the 
bowels.  Of  this  attack  she  nearly  died,  but  after  a  confinement  to  bed  for 
six  weeks  grew  better.  For  two  years  after  this  she  had  irregular,  pain- 
ful, and  profuse  menstruation.  As  she  expressed  it,  whenever  she  became 
fatigued  or  excited,  flooding  would  come  on.  After  this  time  the  men- 
strual periods  disappeared,  and  she  now  applied  for  relief  on  account  of 
amenorrhea  of  three  years'  standing.  Physical  exploration  revealed  the 
uterus  in  normal  position,  though  diminished  in  size  to  about  two  inches. 
Nothing  could  be  ascertained  about  the  ovaries. 

The  view  which  I  took  of  the  case  was  that  pelvic  peritonitis  and  acute 
ovaritis  originally  existed ;  these  left  the  parts  in  such  a  state  that  for  two 
years  metrorrhagia  and  menorrhagia  occurred  ;  then  subsequent  contrac- 
tion occurring  in  the  effused  lymph  in  and  around  the  ovaries,  atrophy 
resulted  with  its  usual  consequence,  amenorrhoja. 

The  peculiarly  destructive  influence  exerted  upon  the  ovaries  by  pelvic 
peritonitis  will  be  impressed  upon  any  one  who  makes  an  autopsy  in  a 
patient  who  has  died  of  that  affection,  or  who  reads  the  reports  of  others. 
Very  often  the  ovaries  cannot  be  discovered  in  the  mass  of  "  putrilage" 
which  occupies  their  site. 

Treatment An  attempt  may  be  made,  by  the  means  recommended  in 

the  treatment  of  undeveloped  ovaries,  to  excite  ovulation  in  any  part  of 
the  glands  which  may  still  be  capable  of  performing  the  function.  But  it 
should  not  be  persisted  in  if  not  at  once  attended  by  good  results,  for  in- 
flammatory action  may  be  excited  by  it.  When  these  means  are  essayed, 
great  caution  should  be  observed  and  their  influence  developed  only  to  a 
limited  degree. 

Ovarian  Apoplexy. 

Definition The  word  apoplexy  is  very  loosely  employed  in  reference 

to  sanguineous  effusions  in  all  the  organs  of  the  body,  some  signifying  by 
it  sudden  vascular  rupture,  while  others  apply  it  to  interstitial  hemorrhage 
occurring  even  very  slowly.  This  has  created  confusion  of  description, 
and  certainly  added  difficulty  to  the  clear  comprehension  of  the  pathologi- 
cal states  to  which  it  has  been  synonymously  applied.  Thus,  in  describing 
ovarian  apoplexy,  Kiwisch1  divides  it  into  primary  and  secondary,  con- 
sidering as  examples  of  the  latter,  hemorrhage  from  the  walls  of  a  cyst 
which  fills  it  slowly  with  blood,  or  hemorrhage  the  result  of  tapping.  The 
two  conditions  should  be  regarded  as  essentially  different,  and  I  would 
offer  this  as  the  proper  definition  of  our  subject.     Apoplexy  of  the  ovary 

1  Op.  cit.,  p.  232. 


6f>4  DISEASES    OF    THE    OVARIES. 

consists  in  a  rapid  effusion  into  its  tissue  of  blood,  which  results  from  rup- 
ture of  one  or  more  of  its  larger  vessels. 

The  ovaries  present  the  only  example  in  the  animal  economy  of  apoplexy 
occurring  as  a  physiological  act.  At  each  menstrual  period,  as  an  ovule 
leaves  its  nidus,  an  apoplexy  from  the  vessels  of  the  tunic  of  the  ovisac 
occurs  as  a  necessary  consequence.  It  is  this  which,  upon  subsequent 
alteration,  constitutes  the  corpus  luteum.  Generally  these  hemorrhages 
are  self-limiting,  and  their  effects  rapidly  disappear;  in  some  cases,  how- 
ever, the  bleeding  continues  too  long  or  returns  after  cessation,  and  then 
the  collection  of  blood  sometimes  reaches  the  size  of  a  man's  fist  or  of  a 
child's  head.1  In  some  instances  the  tunica  albuginea  of  the  ovary  is 
completely  ruptured,  when  the  effused  blood  pours  into  the  most  depend- 
ent portion  of  the  pelvic  cavity,  constituting  pelvic  hematocele. 

Symptoms The  occurrence  of  apoplexy  is  often  ascertained  only  in 

autopsy,  no  signs  existing  during  life  by  which  it  can  be  positively  diag- 
nosticated. The  symptoms  which  will  usually  point  to  its  existence  are 
sudden  and  violent  pain  over  the  region  of  one  ovary,  with  sense  of  great 
exhaustion,  nausea,  and  vomiting.  These  symptoms,  if  combined  with 
enlargement  and  tenderness  of  one  ovary,  as  ascertained  by  conjoined 
manipulation,  will  be  sufficient  to  render  a  diagnosis  warrantable  if  the 
patient's  health  has  previously  been  good. 

Prognosis — The  great  danger  from  the  accident  is  peritonitis,  arising 
either  from  implication  of  the  peritoneal  fold  which  makes  the  broad  liga- 
ment, or  from  rupture  of  the  cortical  portion  of  the  ovary  and  occurrence 
of  hematocele. 

Treatment Should  there  be  symptoms  of  peritonitis,  the  treatment 

elsewhere  recommended  should  be  adopted.  Beyond  this,  all  that  can  be 
done  is  to  keep  the  patient  quiet  in  the  recumbent  posture,  and  prevent 
all  muscular  effort  until  absorption  occurs. 

Displacement  of  the  Ovaries. 

The  extreme  mobility  of  these  glands  and  the  laxity  of  their  supports 
have  already  been  remarked  upon.  Any  influence  which  increases  their 
weight,  draws  upon  them  directly,  or  acts  upon  them  by  traction  through 
a  neighboring  organ,  may  cause  them  to  leave  their  position,  and  even  in 
rare  cases  to  pass  out  of  the  pelvis  in  the  form  of  hernia.  For  example, 
they  may  be  displaced  by  inflammation,  hypertrophy,  ovarian  IVetation, 
etc.,  which  cause  increase  of  weight;  or  they  may  be  acted  upon  by  con- 
tractions of  effused  lymph,  resulting  from  pelvic  peritonitis;  contraction 
of  the  ovarian  ligaments,  etc.,  drawing  them  out  of  place ;  or  they  may 
be   aflected  by  displacement  of  the  uterus,  pregnancy,  or  hernia  of  any 

1  Kiwisch,  op   cit.,  p.  232. 


OVARITIS.  665 

of  the  abdominal  viscera  acting  upon  them  by  means  of  traction.  A 
hernia  of  the  ovary  alone  is  very  rare  ;  it  is  almo3t  always  attended  by 
hernia  of  the  Fallopian  tube,  or  some  portion  of  the  intestines  or  omentum. 

The  ovaries  often  fall,  when  their  weight  is  increased,  into  the  cul-de-sac 
of  Douglas.  More  rarely  they  pass  into  the  inguinal  canals,  or  through 
them  into  the  dartoid  sacs  of  the  labia  majora.  Here  they  show  a  monthly 
intumescence,  which  creates  great  local  disturbance,  and  keeps  the  part 
swollen,  heated,  and  tender,  until  ovulation  is  passed.  Deneux1  declares 
that  they  may  enter  the  femoral,  umbilical,  and  ischiatic  openings,  or  form 
a  part  of  ventral  hernia,  and  Kiwisch  has  reported  a  case  in  which  one 
entered  the  foramen  ovale.  The  accident  is  rarely  important  in  its  results 
except  in  reference  to  excluding  the  suspicion  of  other  forms  of  tumor, 
and  avoiding  the  danger  of  surgical  interference  under  a  mistaken  diag- 
nosis. 

Treatment The  treatment  consists  in  returning  the  displaced  part  by 

taxis,  and  keeping  it  in  situ  by  a  properly  constructed  truss-,  pessary,  or 
bandage.  Should  the  gland  be  bound  in  its  false  position  by  strong  mem- 
branes, the  propriety  of  its  removal  might  be  considered,  in  case  serious 
inconvenience  resulted  from  the  displacement. 

Ovaritis. 

Definition By  this  term  is  meant  an  inflammation  of  the  tissue  com- 
prising the  ovaries,  which  has  been  described  by  some  authors  under  the 
name  of  Oophoritis.  A  dogmatic  treatise  upon  ovaritis  in  the  non-puer- 
peral woman  is,  in  the  present  state  of  science,  impossible.  So  much  con- 
cerning the  disease  is  unsettled,  and  such  utterly  discordant  views  are 
entertained  upon  it  by  the  most  reliable  authorities,  that  too  great  caution 
cannot  be  observed  in  treating  of  the  subject,  lest  theories  constructed 
upon  analogical  reasoning  be  made  to  pass  current  in  the  mind  of  the 
reader  for  facts  faithfully  observed  at  the  bedside  and  in  the  dead-house. 
No  writer  should  attempt  its  description  without  determining  as  Aran 
did,  when  he  penned  the  following  sentence:  "I  leave  out  of  considera- 
tion all  the  fantastic  descriptions  of  ovaritis  which  have  been  constructed 
in  the  library  by  physicians  who  were  more  remarkable  for  brilliancy 
of  imagination  than  knowledge  of  the  disease."  Our  knowledge  of  the 
subject  is  at  least  so  far  advanced  as  to  make  a  theoretical  essay  upon  it 
entirely  inadmissible. 

Varieties Ovaritis  may  be  either  puerperal  or  non-puerperal.     The 

first  does  not  concern  our  present  investigation,  and  we  put  it  out  of  con- 
sideration. The  non-puerperal  form  of  the  disease  has  been  divided  into 
acute  and  chronic,  which  will  now  engage  us  in  order. 

1  Rechercbes  sur  la  Hernie  de  TOvaire. 


666  DISEASES    OF    THE    OVARIES. 


Acute  Ovaritis. 


This  affection,  though  very  common  as  a  result  of  parturition  or  abor- 
tion, is,  except  as  a  complication  of  pelvic  peritonitis  or  cellulitis,  quite 
rare  in  the  non-puerperal  woman.  Mme.  Boivin1  even  goes  so  far  as  to 
say  that,  "  it  would  be  difficult  to  point  to  a  single  well-authenticated  ease 
out  of  the  condition  of  pregnancy."  Dr.  West2  remarks  that,  "  acute  in- 
flammation of  the  substance  of  the  unimpregnated  ovary  is  of  such  rare 
occurrence  that  no  case  has  come  under  my  own  care,  and  but  one  has 
presented  itself  to  my  observation."  Prof.  Fordyce  Barker3  says,  "  I 
doubt  very  much  if  I  have  ever  seen  a  clear,  well-marked  case,  and  I 
have  been  for  years  looking  for  its  existence  in  the  dead-house."  There 
can  be  no  question  of  the  truth  of  these  statements  as  regards  pure  uncom- 
plicated inflammation  of  the  ovary,  but  ovaritis  of  acute  character  going 
on  to  suppuration  or  production  of  a  diffluent  state  of  the  stroma,  is  by  no 
means  rare  as  a  complication  of  pelvic  cellulitis  or  peritonitis.  One  of 
the  greatest  dangers  to  be  feared  from  these  diseases  is  injury  or  destruc- 
tion of  the  ovaries,  and  it  is  probable  that  few  cases  of  cellulitis  and  none 
of  peritonitis  run  their  course  without  involving  them  to  a  greater  or  less 
extent.  It  is  likewise  probable  that  pelvic  peritonitis  is  frequently  excited 
by  some  trouble  originating  in  the  ovaries,  which  are  closely  in  contact 
with  the  peritoneum  making  up  the  broad  ligaments  and  covering  the  pel- 
vic roof.  The  intimate  relation  of  these  parts,  the  ovaries,  the  pelvic 
peritoneum,  and  the  pelvic  areolar  tissue,  accounts  for  the  fact  that  uncom- 
plicated acute  ovaritis  is  rarely  met  with. 

In  proof  of  this  statement  let  me  point  to  the  conditions  of  the  ovaries 
in  the  autopsies  of  periuterine  cellulitis  reported  by  Aran.  In  almost  all 
instances  they  were  diseased,  and  they  generally  contained  pus.  So  com- 
mon was  this  lesion  that  Aran  was  persuaded  that  "  the  purulent  collec- 
tions which,  as  a  consequence  of  periuterine  inflammation,  discharge 
themselves  into  the  peritoneum  or  into  the  organs  in  the  neighborhood  of 
which  they  are  placed,  rectum,  bladder,  vagina,  etc.,  sometimes  even  by 
the  surface,  belong  more  particularly  to  the  ovary  or  tube." 

Since  the  writings  of  Aran,  no  one  has  done  more  to  put  in  a  strong 
and  proper  light  the  intimate  relations  existing  between  inflammation  of 
the  ovaries,  suppuration,  and  pelvic  peritonitis  and  cellulitis  than  Dr. 
Matthews  Duncan.  He  regards  these  periuterine  inflammations  as  always 
symptomatic  affections ;  as  secondary  to  uterine,  tubal,  or  ovarian  dis- 
ease, or  noxious  discharges  entering  the  peritoneal  cavity  through  the 
tubes.  At  the  same  time  that  I  differ  from  Dr.  Duncan,  in  looking  upon 
periuterine  inflammation  as  .not  infrequently  primary,  and  as  commonly 

'  Op.  cit.  2  Op.  cit.,  p.  473. 

»  Bui.  N.  Y.  Acad.  Med.,  vol.  i.  p.  549. 


ACUTE    OVARITIS.  667 

resulting  in  acute  or  chronic  ovaritis  and  abscess,  I  admit  that  the- 
sequence  of  events  is  often  that  which  he  states. 

Authors  have  divided  acute  ovaritis  into  parenchymatous,  follicular, 
and  peritoneal,  but  in  an  affection,  the  mere  recognition  of  which  is  so 
difficult,  it  is  hardly  wise  to  refine  upon  its  peculiarities.  The  form  of 
the  affection  styled  peritoneal  is  really  not  ovaritis,  but  peritonitis  of  the 
very  character  of  which  we  are  speaking  ;  from  which  to  parenchymatous 
and  follicular  disease  there  is  only  one  step.  As  an  example  of  ovaritis 
complicated  with  peritonitis  in  a  non-pregnant  woman,  I  avail  myself  of 
the  kindness  of  Dr.  Roth,  and  record  the  following  history  prepared  by 
him. 

"M.  S.,  ret.  35,  married  ten  years,  had  a  miscarriage  nine  years  ago. 
Since  that  time  has  suffered  from  dysmenorrhea  and  gastric  disorder, 
which  was  styled  dyspepsia.  Two  years  ago  she  applied  to  me,  and  I 
found  her  suffering  from  profuse  fluor  albus  and  retroflexion  of  the  womb. 
Under  use  of  caustics  and  tonics  she  improved  very  much,  and  treatment 
was  stopped.  I  did  not  see  her  again  until  August  1,  18G6,  when  I  found 
her  in  a  convulsion.  After  it  had  passed  off  she  vomited  constantly,  com- 
plained of  great  pain  in  the  bowels,  was  very  thirsty,  and  the  pulse  was 
near  a  hundred.  Opium  was  freely  administered.  On  the  next  day  the 
pulse  was  over  one  hundred ;  skin  hot  and  dry ;  and  she  complained  of 
severe  pain  in  back  and  loins,  and  over  left  iliac  fossa.  I  made  a  vaginal 
examination  by  touch,  but  could  discover  nothing,  except  that  the  vagina 
was  very  hot  and  dry.  Aug.  3.  No  great  change,  except  that  the  abdo- 
men became  tympanitic.  Aug.  4.  She  lost  about  five  ounces  of  blood  per 
vaginam  ;  symptoms  unchanged.  Aug.  6.  She  was  seen  in  consultation 
by  Prof.  Thomas,  who  diagnosticated  pelvic  peritonitis  with  probable 
acute  ovaritis  on  left  side,  and  anticipated  formation  of  an  abscess  near  or 
in  the  ovary.  By  his  advice  a  large  blister  was  applied  over  the  hypo- 
gastrium,  and  opium  given  in  very  large  doses.  The  case  went  on  in 
this  way  until  Aug.  11th,  when  she  suddenly  vomited  a  large  amount  of 
bile,  became  collapsed,  and  died  that  night. 

"Autopsy  eighteen  hours   after  death The  peritoneum  covering  the 

pelvic  viscera  was  covered  with  a  recent  lymph,  and  between  the  organs 
a  great  deal  of  puriform  serum  existed.  Abdominal  peritoneum  healthy. 
The  left  ovary,  which  was  agglutinated  to  the  intestines,  tube,  and  uterus, 
was  about  the  size  of  a  hen's  egg.  In  its  removal  it  was  broken,  and 
several  ounces  of  pure  pus  escaped.  No  evidences  of  cellulitis  could  be 
discovered  upon  careful  dissection.     Other  organs  healthy." 

Pathology This  is  not  clearly  made  out,  though   it  appears  safe  to 

accept  the  stages  described  by  Mme.  Boivin:  first  stage,  congestion,  with 
increase  of  weight  and  rotundity;  second  stage,  the  organ  double,  triple, 
or  quadruple  its  normal  size,  tissue  soft  and  infiltrated  with  yellow  and 
violet-colored  serum,  with  slight  effusion  of  blood  ;  third  stage,  suppura- 


668  DISEASES    OF    THE    OVARIES. 

tion,  pus  infiltrated  or  collected  in  spots;  fourth  stage,  gray  softening, 
disorganization,  the  gland  becoming  diffluent. 

Causes. — The  causes  of  the  disease  may  be  thus  enumerated : — 
Pelvic  peritonitis ; 
Periuterine  cellulitis ; 
Gonorrhoea ; 
Disturbance  of  menstruation. 

Any  of  the  causes  which  have  been  spoken  of  as  sufficient  to  cause  the 
first  two  diseases  mentioned  may  through  them  produce  ovaritis.  A  form 
of  ovaritis  called  blennorrhagic  is  admitted  by  most  authors  as  correspond- 
ing with  blennorrhagic  orchitis  in  the  male.  It  is  difficult  to  see  how 
even  the  progress  of  gonorrhoeal  inflammation  along  the  tubes  would  cause 
disease  of  an  organ  not  connected  with  the  extremities  of  these  tubes,  but 
let  it  be  remembered  that  gonorrhoea  is  in  this  way  one  of  the  most  fruit- 
ful sources  of  pelvic  peritonitis,  and  an  exploration  of  ovaritis  as  a  secon- 
dary result  will  suggest  itself.  Suppression  of  menstruation,  or  any  sudden 
and  violent  shock  given  to  the  ovaries  while  ovulation  is  progressing  and 
the  walls  of  the  organ  are  about  being  broken  through,  may  likewise 
induce  it. 

Symptoms The  symptoms  of  this  affection  are  so  intimately  associated 

with  those  of  peritonitis  and  cellulitis  that  it  is  impossible  to  separate 
them.  There  is  severe  pain  in  one  or  other  iliac  fossa,  with  increase  of 
heat,  fever,  and  perhaps  chill.  Pressure  shows  the  most  exquisite  sensi- 
tiveness, and  when  the  part  is  examined  by  conjoined  manipulation  this 
is  excessive.  By  that  means  the  ovary  is  felt  enlarged  and  generally 
depressed  in  the  pelvis.  These  symptoms  may  subside  upon  the  occur- 
rence of  resolution  in  four  or  five  days;  or  pus  forming  within  the  gland 
may  be  discharged  into  the  peritoneum,  the  rectum,  the  vagina,  or  the 
bladder. 

Differentiation This  is  generally  impossible.     The  association  of  the 

disease  with  those  which  have  been  mentioned  as  being  at  times  its  causes, 
at  others  its  consequences,  is  usually  too  intimate  for  its  distinction  from 
them.  Should  conjoined  manipulation  discover  the  ovary  as  a  round  ball, 
very  sensitive,  and  unassociated  with  fixation  of  the  uterus,  a  diagnosis 
would  be  admissible.  I  have  never  met  with  such  a  case  of  acute  charac- 
ter, nor  is  it  likely  that  it  often  occurs,  though  in  subacute  or  chronic 
ovaritis  these  physical  signs  are  common. 

Prognosis. — The  prognosis  is  favorable,  though  never  free  from  an  ele- 
ment of  doubt. 

Treatment Leeches  may  be  applied  around  the  anus,  over  the  diseased 

organ,  or  at  the  groin.  Should  its  weight  not  give  pain,  a  poultice  should 
then  be  placed  over  the  hy|>ogastrium,  and  opium  freely  administered  by 
mouth  or  rectum.  The  patient  should  be  kept  perfectly  quiet,  and  not 
allowed  to  rise  from  her  bed  even  for  relief  to  the  calls  of  nature.     Espe- 


CHRONIC    OVARITIS.  6G9 

cial  care  in  this  regard  should  be  observed  if  it  be  supposed  that  suppura- 
tion has  occurred,  for  then  a  very  slight  eflbrt  might  cause  a  rupture  of 
the  abscess  into  the  peritoneum. 

Chronic  Ovaritis. 

Chronic  inflammation  of  the  ovaries  is  an  affection  of  common  occur- 
rence, though  very  little  has  been  ascertained  as  to  the  exact  frequency  of 
the  disease.  So  great  is  the  sympathy  existing  between  the  uterus  and 
these  organs,  that  uterine  disorders  excite  ovarian  pain  very  commonly, 
and  give  rise  to  many  symptoms  which  are  regarded  as  characteristic  of 
this  disease.  Again,  it  is  a  well-ascertained  fact  that  slight  attacks  of 
chronic  pelvic  peritonitis  are  extremely  common,  and  unfortunately  we 
possess  no  certain  means  for  distinguishing  such  a  disorder,  in  the  vicinity 
of  an  ovary,  from  chronic  ovaritis. 

In  the  great  majority  of  cases  of  uterine  disease  the  patient  will  com- 
plain of  pain,  of  dull,  aching  character,  over  one  or  both  ovaries,  and  this 
will  very  likely  be  augmented  by  menstruation.  But  it  is  by  no  means  to 
be  concluded  that  this  sympathetic  pain,  even  if  dependent,  as  it  very 
often  is,  upon  congestion,  is  due  to  chronic  ovaritis.  As  well  might  it  be 
believed  that  mammary  pains  excited  in  the  same  manner  are  due  to 
mammitis. 

As  a  primary  affection  which  creates  secondary  uterine  disorder  and 
results  in  dysmenorrhcea,  sterility,  and  hysteria,  it  is  by  no  means  rare. 
Many  cases  supposed  to  be  obscure  and  unmanageable  ones  of  uterine  dis- 
order, many  in  which  the  physician  is  sorely  puzzled  in  accounting  for  the 
wonderful  disproportion  between  the  existing  symptoms  and  the  degree 
of  uterine  disorder  discoverable,  are  due  to  this  affection.  Instances  will 
not  rarely  be  met  with  in  which  with  slight  uterine  displacement,  and  a 
catarrh  of  no  great  moment,  a  patient  will  be  entirely  unable  to  stand  or 
walk,  except  for  very  short  periods  of  time,  will  for  years  prove  sterile, 
and  will  suffer  from  agonizing  dysmenorrhcea  from  this  cause.  The 
revival  of  uterine  pathology  has  drawn  off  attention  too  completely  from 
the  ovaries.  The  coming  decennium  will,  I  feel  convinced,  prove  that  in 
many  cases  disease  of  these  most  important  organs  in  the  female  economy 
is  the  source  of  many  ills  now  attributed  to  that  less  important  viscus  the 
uterus.  It  is  in  the  study  of  ovarian,  not  uterine,  pathology,  that  the 
next  great  advances  in  gynecology  are  to  be  made. 

Symptoms The  symptoms  of  chronic  ovaritis  are  numerous  and  often 

perplexing  ;  no  two  cases  of  the  affection  presenting  the  same  features.  In 
some  they  are  physical  entirely,  while  in  others  the  mind  and  nervous 
system  are  decidedly  involved.  In  several  cases  in  my  experience  true 
epilepsy  has  existed,  whether  as  a  consequence  or  not  I  canrot  say,  but 
certainly  as  a  very  suspicious  complication. 


670  DISEASES    OF    THE    OVARIES. 

The  rational  signs  may  be  enumerated  as— . 

Dysmenorrhoea ; 

Fixed  pain  over  one  or  both  ovaries ; 

Tendency  to  hysteria ; 

Rarely  inability  to  stand  or  walk  ; 

Sometimes  pain  on  sexual  intercourse ; 

Pain  and  exhaustion  after  defecation  ; 

Pain  in  rectum  and  down  thighs  ; 

Irregular  menstruation ; 

Frequently  leucorrhoea ; 

Sterility  if  both  ovaries  are  diseased. 
Dysmenorrhoea  often  precedes  menstruation  by  several  days.  At  other 
times  it  occurs  just  after  the  cessation  of  the  menstrual  discharge  ;  while 
in  a  few  cases  it  occurs  in  the  interval  between  the  menstrual  periods. 
The  last  constitutes  the  intermediate  dysmenorrhoea  of  Dr.  Priestly,  and 
is  a  most  interesting  symptom.  At  times  it  occurs  with  great  regularity. 
In  one  case  which  occurred  in  my  practice  it  showed  itself  invariably  on 
the  ninth  day,  and  in  another  on  the  fourteenth.  Ovarian  dysmenorrhoea 
produces  great  nervous  disturbance,  which  renders  the  patient  peculiarly 
prone  to  seek  relief  in  the  use  of  opium. 

I  have  met  with  several  cases  of  this  disease  in  which  the  patients  have 
been  unable  to  stand  or  walk,  except  for  a  few  minutes. 

If  the  ovary  be  prolapsed,  sexual  intercourse  often  proves  a  source  of 
pain,  but  not  otherwise. 

The  menstrual  discharge  is  sometimes  very  irregular,  remaining  absent 
for  months,  and  then  showing  itself  as  an  alarming  hemorrhage.  In  many 
cases  it  is  quite  regular  both  as  to  time  of  occurrence  and  amount. 

The  continued  uterine  irritation  kept  up  by  chronic  ovaritis  often  en- 
genders uterine  catarrh,  which  proves,  in  consequence  of  its  cause,  very 
intractable  to  treatment. 

That  in  many  cases  the  patients  become  pregnant  cannot  be  questioned, 
but,  as  a  rule,  where  both  ovaries  are  diseased  sterility  exists.  It  is 
highly  probable  that  the  diseased  organs  produce  diseased  or  imperfect 
ova. 

Physical  Signs The  patient  being  examined  by  touch  and  conjoined 

manipulation,  the  uterus  will,  for  some  reason  which  I  cannot  appreciate, 
be  usually  found  to  deviate  from  its  normal  axis,  laterally,  anteriorly,  or 
posteriorly,  and  from  the  cervical  canal  a  thick,  mucous  plug  will  often  be 
found  to  hang.  In  Douglas's  cul-de-sac,  on  one,  or  on  each  side  of  the 
uterus,  a  round,  soft,  tender  body,  about  as  large  as  a  walnut,  will  be 
found.  This,  when  caught  between  the  fingers,  in  conjoined  manipulation, 
will  prove  very  sensitive  to  pressure,  which  will  often  produoe  nausea  and 
tendency  to  hysteria  ;  and  even  after  it  has  been  desisted  from,  a  dull 
aching  pain  will  generally  remain. 


CHRONIC    OVARITIS,  071 

Prognosis I  know  of  few  curable  disorders  which  I  dread  so  much  to 

meet  as  this.  The  day  will  probably  come  when  our  treatment  for  it  will 
be  satisfactory  and  efficient,  but  it  has  not  yet  done  so  by  any  means. 
Many  cases  will  entirely  baflle  treatment,  while  all  will  prove  little  ame- 
nable to  it.  That  they  often  in  time  recover  is  true,  but  recoveries  have, 
mi  my  experience,  but  little  connection  with  treatment. 

Treatment I  have  nothing  better  to  offer  than  the  following  course,  the 

meagreness  of  which  I  regret.  If  the  ovaries  be  found  prolapsed  they 
should  be  carefully  sustained  by  a  light,  elastic  ring  pessary,  and  if  the 
displaced  uterus  press  upon  them  it  should  be  kept  in  position.  Sexual 
intercourse  should  be  limited  as  far  as  possible.  If  scanty  menstruation 
exist  as  a  symptom,  one  or  two  leeches  should  be  applied  every  month  to 
the  cervix  uteri.  Rest  should  be  prescribed  during  menstrual  epochs, 
when  the  diseased  glands  are  congested  and  in  a  state  of  nervous  excite- 
ment. Severe  exercise  or  fatiguing  occupations  should  be  avoided,  and 
all  influences  calculated  to  depress  the  vital  forces  carefully  guarded 
against.  Counter-irritation,  by  means  of  small  blisters,  tincture  of  iodine, 
or  issues  of  nitric  acid,  should  be  kept  up  over  the  diseased  organs  for 
months  at  a  time,  and  once  or  twice  a  week  the  cervix  uteri  and  the  whole 
upper  part  of  the  vagina  should  be  painted  over  with  tincture  of  iodine. 
Every  night  and  morning  the  patient  should  be  directed  to  use  copious  in- 
jections of  warm  water  into  the  vagina  in  the  manner  elsewhere  explained. 
For  the  various  nervous  symptoms  which  accompany  the  affection  the 
bromide  of  potassium  in  ten  to  fifteen  grain  doses  will  be  found  very 
beneficial.  Utero-gestation,  which  secures  the  ovaries  from  monthly 
congestions  for  nine  months,  is  always  much  to  be  desired  under  these 
circumstances. 

Should  evidence  be  elicited  that  small  cysts  exist  in  the  enlarged  and 
tender  ovaries,  they  may  with  advantage  be  punctured  and  evacuated  by 
the  smallest  needle  of  the  aspirator,  the  operation  being  performed  anti- 
septically. 

It  is  now  six  years  since  the  publication  of  the  last  edition  of  this  work, 
and  during  that  time  no  disease  has  more  especially  commanded  my  close 
scrutiny  than  this,  and  yet,  in  an  amended  edition  after  that  lapse  of  time, 
I  find  myself  unable  to  offer  any  improvement  upon  what  was  written 
then! 


672  OVARIAN    TUMORS. 


CHAPTER    XLVII. 

OVARIAN  TUMORS. 

"Witiiix  the  last  twenty-five  years  important  advances  have  been  made 
in  our  knowledge  of  those  pathological  developments  called  tumors.  The 
progress,  which  about  the  beginning  of  that  period  Kokitansky  inaugu- 
rated, has  since  culminated  in  the  eminent  labors  of  Virchow.  Had  we 
now  reached  a  standpoint  which  gave  complete  satisfaction  to  pathologists, 
it  would  be  an  easy  matter  to  offer  a  simple  digest  of  the  whole  subject 
for  the  contemplation  of  the  student.  But  this  is  far  from  being  the 
present  aspect  of  the  subject.  Changes  are  constantly  being  made  in 
nomenclature  ;  views  as  to  pathology  are  daily  being  altered  ;  and  classi- 
fication is  in  consequence  undergoing  frequent  alterations.  This  presents 
evident  difficulties  for  one  who,  not  being  entitled  by  personal  researches 
to  original  views,  is  forced  to  rely  upon  the  workers  in  pathological' 
anatomy  for  his  authority.  All  who  have  really  studied  the  subject  of 
tumors  will  admit  the  force  of  this  statement,  and  from  such  I  have  no 
fears  of  a  severe  judgment  upon  the  table  by  which  I  here  endeavor  to 
display  at  a  glance  the  varieties  of  ovarian  tumors.  I  am  fully  aware  of 
its  imperfections,  but  I  know  of  no  better  method  for  simplifying  a  difficult 
subject  so  as  to  make  it  easily  comprehensible  to  the  general  reader,  and 
none  which  will  prove  so  useful  in  clinical  investigation. 

For  the  purpose  of  facilitating  the  clinical  study  of  ovarian  tumors,  it 
is  probably  best  to  consider  them  under  two  heads :  first,  those  which  are 
solid  and  free  from  cystic  development ;  second,  those  which  are  charac- 
terized by  such  development. 

The  following  table  presents  at  a  glance  these  genera  and  those  of  their 
species  which  are  met  with  at  the  bedside,  not  as  pathological  curiosities, 
but  as  diseased  conditions  requiring  surgical  interference.  Certain  forms 
which  are  rarely  met  with,  even  by  the  most  industrious  morbid  anato- 
mists, will  receive  casual  mention,  but  I  cannot  believe  that  good  arises 
from  blending  these  in  description  with  others  which  are  constantly  pre- 
senting themselves  to  the  attention  of  the  practitioner.  I  also  introduce 
here  a  table  presenting  other  pelvic  cysts  resembling  ovarian  cysts  so 
closely  that  a  differentiation  is  exceedingly  difficult. 


CARCINOMA. 


073 


Ovarian 
tumors 


Solid  tumors 


Cystic  tumors 


Pelvic    cysts    closely   resembling 
ovarian 


(  Carcinoma  ; 

(  Fibroma. 

Cysto-carcinoma ; 
Cysto-fibroma  or  sarcoma  ; 
Dermoid  cysts ; 
'Ovarian  cysts  and  cystomata. 

Cysts  of  broad  ligaments  ; 

Parasitic  cysts  ; 

Ilydro-salpinx  ; 

Uterine  cysts  and  fibro-cysts  ; 

Encysted  peritoneal  dropsy ; 

Subperitoneal  cysts ; 

Cysts  connected  with  the  spinal  cord; 

Renal,  splenic,  and  hepatic  cysts. 

Under  the  head  of  solid  tumors,  enchondroma  and  osteoma  have  been 
reported,  but  the  authenticity  of  the  few  cases  noted  is  very  doubtful. 
Under  that  of  cystic  tumors  might  be  mentioned  hydrops  folliculorum, 
which  sometimes  creates  a  sac  as  large  as  a  child's  head,  and  Rindfleisch 
describes  a  rare  form  of  cysto-colloid  degeneration  of  both  ovaries  growing 
larger  than  a  man's  fist,  to  which  he  applies  the  name  of  struma  ovarii. 
These  affections,  of  great  interest  to  the  pathologist,  I  have  not  thought 
it  best  to  classify  with  the  more  frequent  forms  of  ovarian  disease  which 
commonly  call,  not  for  diagnosis  merely,  but  for  surgical  interference,  for 
fear  of  uselessly  complicating  the  already  difficult  subject  of  diagnosis. 

Carcinoma. — The  ovary  may  be  affected  by  several  varieties  of  cancer- 
ous deposit,  which  are  here  placed  before  the  reader : — 

1.  It  may  be  affected  by  true  scirrhous  degeneration.  This  form  of  can- 
cer is  less  common  than  others,  occurs  usually  after  middle  life,  and  may 
create  a  tumor  of  large  dimensions.  It  develops  slowly,  and  presents  the 
physical  appearance  of  scirrhous  disease  in  other  organs  ;  it  may  be  a  pri- 
mary malignant  development ;  or  it  may  occur  in  the  ovary  secondarily, 
its  primary  development  having  been  previously  recognized  in  some  other 
part  of  the  system. 

2.  The  ovary  may  be  the  seat  of  medullary  cancerous  deposit,  which 
may  originate  in  the  vesicles  of  De  Graaf ;  in  a  corpus  luteum,  as  Roki- 
tansky  once  saw  it  do ;  or  in  the  stroma  of  the  organ.  Distention  some- 
times causes  rupture  of  the  tunica  albuginea  of  the  ovary,  and  then  exube- 
rant medullary  growth  develops  in  contact  with  the  peritoneum  and 
abdominal  viscera. 


1  A  cyst  is  a  collection  of  fluid  developed  within  a  pre-existing  sac  ;  a  cystoma 
one  which  creates  its  own  sac. 
43 


674  OVARIAN    TUMORS. 

3.  Scirrhous  or  medullary  cancer  may  alone  or  united  attack  the  wall 
of  a  cyst,  and  develop  either  as  an  endogenous  or  exogenous  production. 
The  cancerous  matter  so  completely  invades  the  cyst  walls  in  some  cases 
as  to  make  it  appear  that  cystic  degeneration  had  occurred  secondarily  to 
its  deposit. 

4.  From  the  wall  of  a  cyst,  vascular,  arborescent  villi  may  project, 
lining  the  cavity,  and,  in  time,  filling  and  distending  it  so  as  to  cause  the 
rupture  of  its  walls.  Then  the  exuberant  cancerous  element  develops  in 
immediate  contact  with  the  peritoneum,  and  produces  either  a  dangerous 
peritonitis  or  abundant  abdominal  dropsy. 

With  this  form  of  cancer  colloid  degeneration  is  often  associated,  when 
it  constitutes  that  variety  which  has  been  described  by  Cruveilhier  as 
alveolar  cancer. 

The  recognition  of  the  fact  that  the  ovarian  disease  which  affects  a  pa- 
tient partakes  of  the  character  of  any  one  of  the  forms  of  cancer  just  enu- 
merated, must  ever  be  a  matter  of  great  moment,  for  upon  it  must  depend 
not  only  our  prognosis,  but  in  some  cases  the  determination  to  adopt  or 
reject  the  operation  of  ovariotomy.  Even  if  the  case  be  one  of  malignant 
disease,  however,  operative  procedure  may  accomplish  good  by  prolonga- 
tion of  life. 

The  symptoms  which  generally  point  to  the  malignant  character  of  an 
ovarian  tumor  are  these  : — 

1.  The  rapid  development  of  a  solid  tumor  in  an  ovary,  with — 

2.  Marked  depreciation  of  the  strength,  vital  forces,  spirits,  and  general 
condition  of  the  patient. 

3.  The  occurrence  of  oedema  pedum  and  spanaemia  with  a  small  tumor, 
which  are  consequently  dependent  upon  a  general  blood  state,  and  not  the 
results  of  pressure  by  the  tumor. 

4.  Lancinating  and  burning  pains  through  the  tumor. 

5.  Cachectic  appearance. 

G.  The  occurrence  of  ascites  without  evidences  of  cirrhosis  or  other  he- 
patic disease ;  organic  disease  of  the  kidneys,  or  heart ;  or  chronic  peritonitis. 

Cvstic  degeneration  of  the  ovary  sometimes  advances  with  great  nqiid- 
ity,  and  is  accompanied  in  its  course  by  rapid  emaciation,  marked  physical 
prostration,  ascites,  and  a  cachectic  appearance.  It  maybe  asked  whether 
a  case  thus  complicated  would  not  present  the  very  conditions  which  have 
been  pointed  out  as  furnishing  grounds  for  the  diagnosis  of  malignant  dis- 
ease. Unquestionably  it  would.  Let  it  be  remembered  that  while  these 
symptoms  are  mentioned  as  valuable  aids  to  diagnosis,  I  do  not  pretend  to 
maintain  that  they  will  always  enable  the  diagnostician  to  avoid  error. 
Again,  in  citing  ascites  with  a  solid  tumor  as  a  most  important  symptom 
of  malignant  ovarian  disease,  I  do  not  allude  to  slight  or  even  moderate 
effusion  with  a  large  growth,  but  a  markedly  disproportionate  amount  of 
fluid,  a  frreat  deal  of  abdominal  effusion  with  a  very  small  tumor. 


FIBROMA,   OR    FIBROUS    TUMOR.  G75 

Besides  the  condition  just  mentioned  there  are  two  others  which  may 
create  difficulty  in  differentiation  from  ovarian  cancer :  one  is  pregnancy 
in  the  middle  or  latter  months,  complicated  by  peritoneal  effusion  ;  the 
other,  a  uterine  fibroid  existing  with  attendant  dropsy.  The  first  may 
generally  be  known  by  its  characteristic  symptoms ;  while  the  second, 
although  it  might  be  recognized  by  the  physical  and  rational  signs  of  ute- 
rine fibroids,  would  very  likely  give  considerable  trouble  in  diagnosis. 

When  difficult  and  obscure  cases  present  themselves  in  which  a  positive 
diagnosis  becomes  impossible  by  ordinary  means,  paracentesis,  explorative 
incision,  or  both,  should  be  resorted  to  rather  than  that  the  patient  should 
be  deprived  of  the  prospect  for  cure  held  out  to  her  by  ovariotomy.  Very 
often  the  most  doubtful  case  may  be  satisfactorily  settled  by  evacuating 
the  abdominal  effusion,  and  passing  the  index  finger  or  the  hand  through  a 
small  opening  in  the  peritoneum  so  as  to  touch  the  morbid  growth.  In 
certain  rare  cases  even  this  would  not  suffice  to  remove  all  doubt. 

By  the  means  mentioned  I  have  succeeded  in  making  a  correct  diagnosis 
in  many  cases  of  true  ovarian  cancer,  but  in  relying  upon  them  I  have 
twice  failed  entirely,  pronouncing  as  cancer  what  afterwards  turned  out  to 
be  benign  growths.  Cystic  ovarian  tumors  may  unquestionably  produce 
excessive  ascites  and  all  of  the  other  rational  signs  which  I  have  here 
recorded  as  evidences  of  cancer. 

Fortunately  we  are  not  called  upon  now  to  rely  upon  these  imperfect 
means.  A  very  valuable  addition  to  our  means  for  diagnosticating  carci- 
noma of  the  ovary  has  within  the  last  three  years  been  put  at  our  disposal 
by  Drs.  Foulis  of  Edinburgh,  and  Thornton  of  London,  each  working  with- 
out knowledge  of  the  other's  labors.  They  have  found  that  if  the  peri- 
toneal fluid  which  has  been  in  contact  with  malignant  ovarian  tumors  be 
examined  microscopically,  it  will  be  very  generally  found  to  contain  germs 
which  will  announce  the  fact  and  put  us  on  our  guard  as  to  the  nature  of 
the  disease.  Their  statements  may  be  found  in  the  British  Medical  Journal 
for  July  and  September,  1877,  and  are  well  worth  careful  study. 

Fibroma,  or  Fibrous  Tumor This  form  of  tumor  is  rarely  met  with  in 

the  ovary,  and  never  attains  a  very  great  size.  Kiwisch  reports  two 
cases,  one  the  size  of  a  child's,  and  the  other  the  size  of  a  small  adult 
head.  Dr.  Farre  discredits  the  reports  of  large  ovarian  fibroids  which 
are  upon  record,  and  believes  them  to  have  been  in  reality  either  cancer- 
ous tumors  or  growths  connected  with  the  uterus,  which  so  encroached 
upon  the  ovaries  as  to  seem  to  have  sprung  from  them.  Periuterine 
fibroids  which  spring,  not  from  the  uterus  itself,  but  from  the  extension  of 
uterine  fibres  into  the  broad  and  utero-sacral  ligaments,  have  probably 
often  given  rise  to  errors  in  reports  of  such  tumors.  Many  of  the  reported 
cases  of  ovarian  fibroids  have  likewise  been  due  to  confusion  of  this  form 
of  tumor  with  cysto-fibroma.  When  the  disease  does  affect  the  ovary,  it 
differs  in  no  essential  degree  from  the  same  affection  of  the  uterus,  except 


676  OVARIAN    TUMORS. 

that  pediculation  does  not  occur  as  in  the  latter  organ,  and  that  the 
growth  of  the  tumor  is  much  more  limited. 

The  reader  must  be  reminded  that  these  remarks  apply  to  the  pure 
fibroid  and  not  the  fibro-cystic  ovarian  tumor,  which  may  attain  an  im- 
mense size,  and  is  always  to  be  regarded  as  a  serious  disease.  They  like- 
wise apply  to  the  development  of  fibroid  tissue  into  true  fibromata,  for  in  the 
walls  of  cystic  and  cystomatous  growths  fibroid  tissue  is  commonly  developed. 
Virchow  believes  that  of  the  well-authenticated  cases  of  true  ovarian 
fibroma,  the  size  has  varied  between  that  of  a  hen's  egg  and  that  of  a 
child's  head.  Larger  ones  he  regards  as  cases  of  cysto-fibroma.  Fcerster 
reports,  however,  one  case  in  which  the  tumor  was  as  large  as  a  man's 
head ;  and  Scanzoni  and  Van  Buren  similar  ones.  Dr.  Peaslee1  records 
a  case  where  a  tumor  of  this  kind  of  equal  size  was  removed  by  me  in 
1864,  but  I  cannot  agree  in  his  classification.  It  was,  according  to  my 
view,  a  true  cysto-fibroma.  The  following  was  the  report  of  it  pub- 
lished soon  after  its  removal:  "The  tumor,  when  placed  upon  a  table 
and  palpated,  was  so  deceptive  in  its  apparent  yielding  of  fluctuation,  that 
it  was  even  then  declared  to  contain  fluid  which  had  not  been  reached  by 
the  trocar,  and  this  view  was  entertained  until  it  was  bisected.  It  was 
found  that  it  consisted  of  loose  fibrous  elements,  forming  numerous  loculi, 
about  the  size  of  a  hickory-nut,  which  were  filled  with  a  honey-like  mate- 
rial. After  section  had  allowed  what  was  computed  as  about  three  pounds 
of  this  material  to  flow  away,  the  tumor  weighed  a  little  more  than  four- 
teen pounds." 

Within  the  last  year,  however,  I  have  removed  an  unquestionable 
ovarian  fibroid  as  large  as  the  largest  man's  head. 

If  in  one  of  the  solid  tumors  just  mentioned  cysts  develop  themselves 
as  essential  parts  of  the  growths,  we  give  them  the  names  of  cysto-fibroma, 
cysto-sarcoma,  or  cysto-carcinoma. 

Cyst o-carci noma The  formation  of  fluid  collections  may  occur  with 

cancer  of  the  ovary  in  three  ways:  1st,  cysts  may  develop  in  the  structure 
of  scirrhous  and  medullary  cancers,  as  they  do  in  that  of  sarcomata;  2d, 
a  fluid  or  cystic  tumor,  primitively  benign,  may  develop  malignant  mate- 
rial in  its  cyst-wall ;  3d,  a  large  medullary  cancer  may,  by  cell  infiltration 
and  disintegration  at  its  centre,  form  within  itself  a  mass  of  fluid.  The 
condition  may  consist  then  in  cancer  complicating  cystic  degeneration  or 
in  cystic  degeneration  complicating  cancer.  According  to  Scanzoni,  the 
cancerous  mass  may  develop  in  the  tissue  of  the  cyst  walls  and  project 
either  internally  or  externally,  or  it  may  grow  from  the  walls  by  pedicu- 
lated  or  sessile  tumors  filled  with  medullary  material,  which  are  soft, 
tumefied,  and  very  vascular.  In  the  same  tumor  both  colloid  degeneration 
and  medullary  cancer  may  be  met  with. 

1  Op.  cit.,  p.  2G. 


CYSTO-FIBROMA    OR    CYSTO-S  ARCOMA  .  077 

The  ovarian  limits  do  not  always  confine  these  fatal  growths.  At  times 
they  pass  them,  and  affect  the  peritoneum  or  other  neighboring  parts. 
This  tendency  to  eccentric  development  accounts  for  the  protuberances, 
the  size  of  the  fist,  so  often  serving  as  a  means  of  diagnosis  of  ovarian 
cancer.  The  distinguishing  characteristic  of  cystic  cancer  is  its  rapidity 
of  development.  In  a  few  months  it  often  reaches  a  size  which  sarcoma 
or  even  cystic  degeneration  would  not  attain  for  several  years. 

The  frequency  of  these  and  other  ovarian  tumors  may  be  judged  of  from 
reference  to  some  statistics  accumulated  by  Scanzoni,  which  have  been 
already  referred  to  : — 


Number  of  cases  examined 


1823 

97 
41 


ovarian  tumors  among  them    . 
"  eases  submitted  to  autopsy 

"  fluid  tumors     ...... 

"  colloid  tumors  ..... 

"  cysto-sarcomata         ..... 

"  cystic  cancers  ..... 

From  this  it  will  be  seen  that  the  affection  which  we  are  now  consider- 
ing is  rarer  than  sarcoma  and  very  much  rarer  than  colloid  or  alveolar  de- 
generation. 

Surgical  treatment  holds  out  little  hope  in  these  cases.  According  to 
my  experience,  ovariotomy  performed  upon  patients  thus  affected  almost 
invariably  results  fatally.  Nevertheless,  even  as  a  forlorn  hope,  its  pro- 
priety should  be  considered. 

The  prognosis  in  this  disease  is  graver,  and  the  limit  of  life  shorter  than 
in  any  other  affection  of  the  ovaries. 

Cysto-fibroma  or  Cysto-sarcoma — Between  sarcoma  and  fibroma  of 
the  uterus  a  very  broad  distinction  is  now  made  by  pathologists  and  clini- 
cists,  but  at  present  these  two  terms  are  in  reference  to  the  ovaries  used 
synonymously.  That  they  have  really  been  so  for  a  long  time  in  works 
upon  gynecology,  is  evident  from  an  examination  with  reference  to  the 
subject.  Tims  Scanzoni  defines  fibrous  tumors  of  the  ovaries  to  be 
"  tumors  formed  of  cellular  tissue,"  and  cysto-sarcomata  as  "  tumors  com- 
posed of  cellular  tissue  in  the  middle  of  which  are  formed  more  or  less 
considerable  cavities."  Peaslee  refers  to  cysto-fibroma,  and  makes  no 
mention  of  cysto-sarcoma,  while  Barnes  and  G.  Braun  treat  of  cysto-sar- 
coma without  alluding  to  cysto-fibroma.  It  must  be  remembered  that, 
even  in  reference  to  these  affections  in  general,  ltindfleisch1  says,  ';  I  can- 
not separate  the  fibroma  from  the  sarcoma ;  .  .  .  Ave  distinguish  three 
principal  varieties  of  sarcoma,  namely:  round-celled  sarcoma,  spindle- 
celled  sarcoma,  and  fibroma."  "  By  cysto-sarcomata,"  says  Liicke,2  "  those 
large  tumors  are  especially  meant  which  consist  of  solid  masses,  papillary 

1  Patholog.  Histol.,  Am.  ed.,  pp.  132  and  142.  2  Loc.  cit. 


678  OVARIAN    TUMORS. 

proliferations,  and  numerous  closed  and  open  cavities,  such  as  are  found 
in  the  mammae,  ovary,  and  testicle."  In  some  cases  the  first  step  in  dis- 
ease is  adenoma;  then,  this  being  affected  by  sarcoma,  which  undergoes 
cystic  degeneration,  the  result  is  a  combination  to  which  Liicke  gives  the 
name  adeno-cysto-sarcoma. 

These  cysts  often  grow  to  a  very  large  size.  In  Mr.  Wells's  ninety- 
first  case  of  ovariotomy  the  operation  was  preceded  by  tapping,  which 
removed  thirty-eight  pints  of  thin,  dark  fluid  containing  much  choleste- 
rine.  Dr.  Fox,  who  examined  the  tumor,  states  that  the  cysts  which 
were  emptied  by  tapping  represented  one-half  the  bulk  of  the  mass,  which, 
even  after  this,  weighed  thirteen  pounds.  The  structure  of  the  solid  por- 
tion of  the  tumor  was  very  complex,  the  cysts  being  of  every  variety  of 
size  and  grouped  together  in  great  confusion.  In  some  the  fluid  was  clear, 
and  in  others  like  pea  soup.  The  proportion  between  the  cystic  and  fibrous 
elements  governs  the  character  of  these  masses  to  such  an  extent  that  it 
is  often  difficult  to  classify  them.  When  the  former  is  much  in  the  as- 
cendency, the  growth  resembles  a  fluid  tumor  ;  when  the  latter  predomi- 
nates, it  appears  perfectly  solid. 

The  contents  of  the  cyst  may  be  colloid,  purulent,  serous,  or  sanguino- 
lent,  and  blood  is  sometimes  effused  between  the  fibrous  interstices  so  as 
to  cause  a  rapid  increase  in  size.  The  cystic  sarcoma  sometimes  attains 
very  large,  or,  as  Kiwisch  expresses  it,  "  colossal,"  dimensions. 

In  Mr.  Wells's  case  just  alluded  to,  the  tumor  filled  the  whole  abdomen, 
and  extended  two  inches  above  the  ensiform  cartilage  by  its  upper  margin, 
but  its  growth  was  not  nearly  so  rapid  as  that  of  pure  cystic  disease.  This 
case  had  lasted  for  seven  or  eight  years,  slowly  increasing  until  1863, 
when  it  developed  at  the  following  rate  :  June  to  July,  one  inch  ;  July  to 
August,  one  inch;  August  to  September,  one  inch;  September  to  Octo- 
ber, half  an  inch ;  October  to  November,  one  inch. 

Should  one  or  more  large  cysts  be  detected,  relief  to  many  of  the  symp- 
toms arising  from  mechanical  interference  may  be  obtained  by  tapping. 
The  results  of  the  operation  are,  however,  more  dangerous  than  in  fluid 
tumors,  hemorrhage  and  subsequent  inflammation  often  taking  place  in 
consequence  of  it.  Another  disadvantage  attending  it  is  that  the  operator 
is  more  limited  as  to  choice  of  the  point  to  puncture.  Besides  this  means 
our  efforts  at  palliation  must  consist  in  relieving  symptoms  as  they  occur, 
in  giving  support  to  the  mass  by  an  abdominal  bandage,  and  in  enjoining 
quietude  during  menstrual  epochs. 

The  only  curative  treatment  with  which  we  are  acquainted  that  avails 
anything  for  this  form  of  tumor  is  removal  by  ovariotomy.  The  operation 
is  not  so  promising  as  in  case  of  cystic  degeneration,  and  should  not  be 
undertaken  until  the  evil  results  of  the  disease  and  its  tendency  to  destruc- 
tion of  life  are  fully  manifested.  It  requires,  generally,  the  long  abdomi- 
nal incision,  and  is  very  likely  to  be  rendered  difficult  by  adhesions ;  still 


DERMOID    CYSTS.  679 

the  prospect  of  success  is  such  as  to  render  the  operation  in  many  cases  of 
grave  prognosis  not  only  admissible,  but  incumbent  upon  us. 

Dermoid  Cysts In  various  parts  of  the  body,  the  orbit,  the  floor  of  the 

mouth,  the  brain,  the  eye,  the  anterior  mediastinum,  the  lungs,  the  mesen- 
tery, the  testicles,  and  the  ovaries,  a  peculiar  cyst  containing  fat,  teeth, 
hair,  cholesterine,  cartilage,  and  bone  is  sometimes  found.  Its  wall  gives 
evidences  of  the  existence  of  sweat  glands,  sebaceous  follicles,  papillae,  and 
an  investing  epithelium,  so  that  the  microscopic  appearances  of  the  wall 
resemble  closely  those  of  the  skin.  Many  fanciful  theories  have  been  in- 
dulged in  as  to  the  origin  of  these  peculiar  growths.  It  is  now  generally 
believed  that  they  are  the  result  of  an  irregular  and  eccentric  development 
of  the  tissues  of  the  foetus  during  intra-uterine  life.  It  was  Lebert  who 
advanced  the  theory  that  from  the  elements  present,  spontaneous  genera- 
tion of  a  portion  of  skin  occurs,  and  this  being  given,  we  have,  as  Dr. 
Farre  expresses  it,  "  the  basis  out  of  which  many  of  those  products 
spring." 

M.  Pigne  has  analyzed  eighteen  cases  with  reference  to  the  period  of 
life  at  which  they  were  found,  with  the  following  results : — 

5  existed  in  virgins  under  twelve  years  ; 

6  "  children  from  six  months  to  two  years  ; 
4          "          the  female  foetus  at  term  ; 

3  "  foetuses  cast  off  at  eighth  month. 

Dermoid  tumors  vary  in  size  from  that  of  a  hen's  egg  to  that  of  the 
adult  head,  but  very  rarely  grow  larger.  They  are  hard  and  generally 
globular.  One  ovary  is  usually  affected,  and  by  only  one  tumor ;  but 
instances  are  on  record  where  a  single  ovary  contained  a  large  number. 
They  usually  consist  of  fat,  long  hairs,  teeth,  skin,  and  traces  of  bone 
intermixed.  The  teeth  are  usually  imbedded  in  the  cyst  wrall  or  attached 
to  pieces  of  bone,  and  are  sometimes  very  numerous.  Schnabel1  records 
a  case  in  which  they  exceeded  one  hundred  in  number,  and  Ploucquet2 
one  in  which  they  amounted  to  three  hundred. 

Histories  of  such  cases  are  so  rare  that  I  transfer  the  following  from 
Prof.  Kiwisch's  work:  "A  girl,  seventeen  years  of  age,  was  attacked 
with  a  swelling  of  the  left  ovary  which,  after  twenty-one  years,  meas- 
ured four  ells  in  circumference,  and  reached  below  the  knee.  After 
her  death,  which  took  place  in  her  thirty-eighth  year,  it  was  found  that 
the  sac  alone  of  the  ovary  weighed  fourteen  pounds,  and  contained  forty 
pounds  of  a  thick,  adipose,  honey-like  mass,  which  was  mixed  with  many 
hairs  of  different  lengths,  among  which  curls  were  found  two  inches  long, 
and  as  thick  as  a  thumb,  very  like  elf  locks  ;  the  internal  surface  of  the 
sac  was  set  with  short  hairs.  There  were  also  found  eight  bony  concre- 
tions of  irregular  shape,  one  of  which  was  seven  and  another  ten  inches 

1  Kiwisch,  op.  cit.  2  Becquerel,  op.  cit. 


G80  OVARIAN    TUMORS. 

long,  and  about  two  inches  broad ;  the  form  of  one  of  these  bones  was 
polygonal,  and  set  with  six  molar  teeth  and  one  incisor,  and  nine  separate 
bones  were  present  besides.  The  teeth  had  the  size,  perfectness,  and 
firmness  which  they  generally  have  in  a  girl  twenty  years  of  age." 

Although  in  themselves  innocuous,  and  not  likely  to  increase  rapidly  or 
to  attain  any  great  development,  they  sometimes  set  up  very  serious  and 
even  fatal  disturbance  by  one  of  three  methods :  by  creating  suppuration 
and  abscess  on  account  of  the  irritation  kept  up  by  a  foreign  mass ;  by 
perforation  and  discharge  into  the  peritoneum ;  or  by  the  cyst  which 
contains  the  dermoid  elements  secreting  fluid  and  changing  its  character 
to  that  of  a  fluid  tumor.  Out  of  one  hundred  and  fifty  ovarian  tumors 
removed  by  me,  four  were  large  cysts  having  as  bases  dermoid  tumors 
containing  fat  and  hair,  and  in  one  case  a  small  fragment  of  bone.  In 
these  cases  the  cysts  containing  the  dermoid  elements  were  not  in  com- 
munication with  the  large  cysts  filled  with  fluid  colloid,  which  constituted 
the  mass  of  the  tumor.  In  two  cases  the  tumor  was  nearly  removed  when 
a  cyst  filled  with  fluid,  fat,  etc.,  was  opened  into.  The  large  cysts  ap- 
peared exactly  like  ordinary  multilocular  cystoma. 

Very  often  they  are  discovered  by  accident  only.  Physical  exploration 
reveals  a  hard,  round  mass,  painless  upon  touch,  and,  unless  the  size 
prevent  it,  perfectly  movable.  "When  of  small  size  they  require  no  special 
treatment,  unless,  as  once  happened  in  a  case  of  Dr.  Ramsbotham's,  they 
obstruct  parturition.  When  the  cyst  wall  undergoes  suppurative  action 
and  the  mass  points,  it  should  be  managed  upon  the  same  principles  as  a 
pelvic  abscess.  "When  a  large  cyst  or  cysts  develop,  they  should  be  treated 
as  the  ordinary  cystoma  ovarii. 

"VVe  have  now  reached  the  proper  point  for  the  consideration  of  the 
subject  of  ovarian  cysts  and  cystomata,  which  calls,  on  account  of  its 
paramount  importance,  for  the  closest  investigation  on  the  part  of  the 
gynecologist.  That  it  may  receive  this  I  leave  its  study  for  a  separate 
chapter.  Meantime,  before  leaving  this  part  of  our  subject,  it  appears 
best  to  me  to  say  a  few  words  upon  colloid  degeneration  of  the  ovary,  an 
affection  which  at  present  holds  in  the  minds  of  many  a  doubtful  position 
as  to  malignancy.  For  a  long  time  the  generally  accepted  opinion  with 
reference  to  colloid,  xoxfca,  "glue,"  and  *t$oj,  "like,"  or  jelly-like  tumors 
was  that  they  were  of  cancerous  nature,  but  both  in  their  minute  structure 
and  in  their  clinical  features  they  are  so  far  removed  from  true  malignant 
disease  that  the  belief  is  becoming  very  prevalent  that  they  are  not  neces- 
sarily of  that  character.  This  view  is  now  adopted  by  Drs.  Fane,  G. 
Hewitt.  Kiwisch,  Collis,1  Becquerel,  and  most  of  the  more  recent  writers 
upon  the  subject.  In  speaking  of  ovarian  colloid  tumors,  Hewitt  remarks: 
'•  The  latter  designation  (colloid  cancer)  is  not  a  good  one,  for  an  attentive 

1  Op.  cit.,  p.  205. 


COLLOID    DEGENERATION    OF    THE    OVARY.  081 

consideration  of  the  facts  leads  to  the  conclusion  that  the  affection  is  not 
cancer  at  all."  M.  Becquerel1  seems  to  have  placed  the  question  in  its 
proper  light  when  he  says,  "Several  diseases  have  been  confounded  under 
the  indefinite  name  of  colloid  cysts  ;  it  is  therefore  essential,  before  ad- 
vancing, to  distinguish  these  different  varieties.  AVe  shall  now  endeavor 
to  do  this  after  them  (Virchow  and  Scanzoni),  previously  remarking  that 
under  the  name  of  colloid  matter  some  have  not  at  all  intended  to  signify 
a  cancerous  product,  while  others  have  assigned  it  such  an  origin."  Vir- 
chow2 strongly  expresses  himself  upon  this  point.  In  speaking  of  the 
difference  between  the  form  and  nature  of  growths,  he  says,  "You  may 
therefore  say,  colloid  cancer,  colloid  sarcoma,  colloid  fibroma.  Here 
colloid  means  nothing  more  than  jelly-like."  He  then  goes  on  to  remark 
that  no  confusion  should  exist  between  such  growths  as  colloid  cancer  and 
colloid  degeneration  of  the  thyroid  gland  as  to  pathological  significance. 
His  description  of  the  so-called  alveolar  cancer  is  thus  quoted  by  Bec- 
querel:  "Small  pouches,  which  are  filled  with  gelatinous  matter  and 
whose  walls  are  lined  by  a  layer  of  epithelium,  are  found  in  the  paren- 
chyma of  the  ovary.  These  vesicles  develop  in  every  direction,  but  more 
especially  at  the  periphery  of  the  ovaries,  where  they  form  masses  of 
irregular  shape.  Some  of  them  are  isolated,  while  others  are  grouped 
together  in  the  following  manner.  The  walls  of  these  vesicles  disappear 
by  atrophy  of  cellular  tissue,  when  they  are  only  formed  by  their  epithelial 
lining.  This  becomes  infiltrated  with  fat,  and  the  walls  forming  the 
connection  are  easily  ruptured.     Those  of  the  large  cyst  remain   intact 

and  become  hypertrophied In  other  cases  the  vesicles 

rupture  by  over-distention ;  from  this  results  hemorrhage,  and  blood  is 
found  in  the  vesicles."  Kiwisch  describes  it  as  a  breaking  up  of  the 
stroma  of  the  ovaries  into  cellular  cavities,  alveoli,  closely  aggregated 
together  and  inclosing  a  jelly-like,  semifluid  mass.  By  others  it  has  been 
likened  to  a  sponge  or  a  honeycomb. 

It  is  safe  to  conclude,  from  the  present  aspect  of  the  subject,  that,  while 
colloid  deposit  may  coexist  in  the  ovary  with  true  cancer,  the  peculiar 
breaking  up  of  the  stroma  into  alveoli  which  we  have  just  described  is  not 
in  itself  a  malignant  affection,  but  one  which  seems  to  constitute  a  con- 
necting link  between  cancer  and  the  benign  degenerations.  It  frequently 
complicates  cancer,  sarcoma,  and  fluid  tumors.  "We  have  observed," 
says  Kiwisch,  "  alveolar  degeneration  of  considerable  extent  remain  in  the 
system  for  a  long  series  of  years,  without  any  remarkably  bad  effects." 

Should  a  large  cyst  be  discovered  anywhere,  and  the  size  of  the  tumor 
require  diminution  on  account  of  interference  with  surrounding  parts, 
paracentesis  may  be  practised ;  but  in  a  pure  alveolar  tumor,  such  an  accu- 

»  Op.  cit.,  p.  226.  2  Cellular  Pathol.,  p.  512. 


082  OVARIAN    CYSTS. 

mutation  is  not  common.  Under  these  circumstances,  if  the  disease  stead- 
ily advance  and  the  constitution  suffer  in  consequence,  we  should  be 
encouraged  by  recognition  of  its  non-malignant  nature  to  perform  ova- 
riotomy. 


CHAPTER   XLVIII. 

OVARIAN  CYSTS  AND  CYSTOMATA. 

This  disease  consists  in  the  development  of  cysts  within  the  ovary  with- 
out coincident  growth  of  solid  elements,  such  as  fibroma  or  carcinoma.  Of 
all  the  varieties  of  ovarian  tumor  it  is  the  most  commonly  met  with,  and 
hence  for  the  practitioner  it  is  the  most  important.  It  is  fortunately,  too, 
that  which  above  all  others  is  most  susceptible  of  relief  by  surgery. 

Pathologists  are  still  at  variance  with  reference  to  the  origin  of  ovarian 
cysts.  While  some  with  Wilson  Fox1  agree,  that  "  all  the  forms  of  cysts 
met  with  in  the  ovary  originated  from  the  Graafian  follicles,  and  that  the 
multilocular  forms  are  not  the  results  of  any  special  degeneration  of  the 
stroma  ;"  others,  like  Wedl,  doubt  their  follicular  origin  entirely ;  and 
others  still,  with  Rindfleisch,  admit  two  different  sources  of  cystic  forma- 
tion— one,  the  follicles,  the  other,  the  interstices  of  the  stroma. 

"  In  many  cases,"  says  Rokitansky,2  "  they  are  undoubtedly  formed 
from  the  Graafian  follicles,  and  it  appears  that  an  inflammatory  process  is 
particularly  liable  to  give  the  first  impulse  to  this  metamorphosis.  They 
are  probably,  however,  as  often  new  formations  from  the  beginning." 

"It  was  formerly  very  generally  supposed,"  says  Wedl,3  "that  the  cysts 
in  the  parenchyma  of  the  ovary  originated  in  the  Graafian  follicles,  but  no 
direct  proof  of  this  was  ever  given." 

Liicke,4  one  of  the  latest  and  most  reliable  authorities,  takes  even 
stronger  ground  against  it  than  Wedl  did.  After  quoting  Rokitansky's 
views  he  goes  on  to  say  :  "  But  we  have  already  stated  that  cysts  can  only 
form  in  the  connective  tissue,  and  only  after  a  long  continued  irritation  ; 
and  that  it  does  not  look  at  all  probable  that  such  cysts  should  form  by 
spontaneous  exudation.  As  far  as  the  cystoids  of  the  ovary  are  concerned, 
theory  certainly  is  not  admissible.  These  tumors  are  essentially  cysts 
from  broken  down  tissue." 

While  experimental  pathologists  are  testing  this  question,  we  may  for 

•  Med.  Chirurg.  Trans.,  1864.  !  Op.  cit.,  p.  249. 

3  Wedl's  Path.  Histol.,  p.  462. 

4  Chapter  on  Tumors  in  Billroth  and  Pitha's  Manual  of  General  and  Special 

Surgery. 


OVARIAN    CYSTS.  G83 

the  time  assume  that  there  are  two  entirely  different  pathological  processes 
by  which  true  ovarian  cysts  arc  generated  : — 

1st.  The  follicles  of  I)e  Graaf  become  Idled  with  a  colloid  material,  due 
to  abnormal  secretion  from  their  walls,  and,  according  to  Rokitansky  and 
Rindfleisch,1  probably  the  result  of  inflammatory  disease  of  the  wall  of  the 
follicle.  This  is  not  the  insignificant  hydrops  folliculorum  which  creates 
small  cysts,  but  a  true  colloid  degeneration  of  the  follicle  of  much  more 
serious  import. 

2d.  A  development  of  cysts  may  occur  in  the  stroma  of  the  ovary  with- 
out connection  with  the  follicles.  In  this  case,  according  to  Wedl,  "  the 
cyst  consists  in  an  excessive  augmentation  of  volume  of  the  areolae  of  the 
areolar  tissue  and  of  the  papillary  new  formations  composed  of  connective 
tissue."  In  this  view  Waldeyer  coincides  in  his  excellent  treatise  upon 
ovarian  tumors.2 

Liicke  makes  Rokitansky's  view  as  to  the  mode  of  formation  of  these 
cysts  in  the  stroma  so  clear  that  I  use  his  words  instead  of  quoting  the 
original :  "  Cysts  may  also  be  generated  by  exudation  into  new  formed 
connective  tissue— the  fluid  distending  the  different  bundles,  and  as  they 
intersect  in  all  directions,  the  globular  form  is  the  result ;  thus  numerous 
small  spaces  communicate  with  each  other,  from  their  walls  new  cysts 
start,  and  thus  very  complex  tumors  can  be  formed."  Rindfleisch3  accepts 
both  of  these  sources  of  ovarian  cystoma  in  the  following  words :  "  An 
exact  investigation  also  proves  that  at  least  the  majority  of  all  ovarian 
cysts  proceeds  from  Graafian  follicles ;  while,  upon  the  other  hand,  until 
further  information,  a  different  mode  of  origin  must  be  accepted  for  a  group 
of  cysts,  although  not  so  large,  yet,  at  the  least,  just  as  important." 

The  development  of  a  substance  resembling  the  glandular  element  of 
the  ovaries,  and  constituting  the  nidus  of  cysts,  has  recently  attracted 
considerable  attention.  In  18G2  3Ir.  Spencer  Wells  proposed  for  this  the 
name  of  "  adenoma"  or  "  adenoid  tumor."  Further  investigations  appear 
to  have  satisfied  pathologists  that  a  degree  of  adenoid  development  occurs 
in  every  true  ovarian  cystoma.  Mr.  Wells  himself,  in  his  recent  work  on 
Diseases  of  the  Ovaries,  considers  under  the  head  of  adenoid  tumors  all 
simple,  multiple,  and  proliferous  cysts  ;  and  Delafield*  declares,  that  "  in 
the  ovaries  most  of  the  compound  cysts  are  adenomata,  with  dilatation  of 
the  follicles."  Klebs  strongly  advocates  this  view.  As  adenoma  is  then 
a  frequent  element  of  ovarian  cystomata,  it  requires  no  separate  and  spe- 
cial consideration. 

Until  a  recent  period  considerable  attention  has  been  paid  to  the  char- 
acter of  ovarian  cysts,  based  upon  the  existence  of  a  few  and  of  many 
cysts.     Pathologists  are  beginning  to  lay  less  stress  upon  this  feature  than 

1  Op.  cit.,  p.  515.  2  Waldeyer,  Eierstock  und  Ei.,  Leipzig,  1870. 

3  Op.  cit.,  p.  515.  4  Post-mortem  Examinations  and  Morbid  Anatomy. 


C84  OVARIAN    CYSTS. 

they  formerly  did.  Rindfleisch  declares  that  all  are  multilocular  in  the 
beginning,  and  that  they  become  paucilocular,  and,  even  in  rare  cases, 
unilocular,  by  fusion  of  adjacent  cysts  by  breaking  down  of  dividing 
septa.  It  must  be  admitted,  however,  that  there  is  one  class  of  tumors, 
the  distinguishing  characteristic  of  which  is  the  existence  of  a  few  cysts 
only,  one  or  two  of  which  are  usually  very  large,  and  another  which  is 
specially  marked  by  numerous  small  cysts.  The  first  constitutes  the 
olygocystic  tumor  of  Peaslee ;  the  latter  the  polycystic  tumor ;  or,  as  they 
are  likewise  styled,  paucilocular  and  multilocular. 

Each  class  has  usually  certain  well-marked  features,  the  recognition  of 
which  is  of  value  in  a  practical  point  of  view.  The  first  is  thus  described 
by  Rindfleisch  :  "  Multilocular  tumors  up  to  the  size  of  a  man's  head,  or 
unilocular  cysts  up  to  two  feet  in  diameter,  with  smooth,  but  little  ad- 
hering surface,  and  comparatively  thick,  fibrinous  walls,  which  are  very 
commonly  covered  at  their  inner  side  with  cauliflower-like  or  more 
tuberous  papillary  excrescences."  This  is  the  form  of  tumor  which  he 
regards  as  due  to  colloid  degeneration  of  the  Graafian  follicles. 

The  second  variety  he  describes  in  these  words  :  "  At  the  place  of  one 
ovary  (the  other,  as  a  rule,  is  healthy,  while  in  the  first  form  the  disease 
is  often  of  both  sides)  there  lies  a  tumor,  not  infrequently  far  above  the 
size  of  a  man's  head,  which  is  composed  of  several  large,  and  very  many 
smaller,  and  even  the  smallest  cysts.  The  larger  cysts  are  often  con- 
stricted, and  exhibit,  at  these  places,  the  remains  of  former  partition  walls 
in  the  form  of  fenestrated  membranes,  or  ramified  vascular  strands,  which 
evidently  succumb  to  a  gradual  maceration.  The  surface  of  the  tumor  is 
probably  always  connected  with  the  peritoneum  by  a  large  number  of  in- 
flammatory adhesions,  upon  which  larger  venous  vessels  run  to  and  fro. 
The  walls  of  the  cysts  are  comparatively  thin,  and  easily  torn."  These 
tumors  he  regards  as  due  to  colloid  degeneration  of  the  stroma. 

"While  the  statement  of  Rindfleisch  that  no  "  fundamental  significance" 
can  be  attributed  to  the  unilocular  or  multilocular  character  of  these 
tumors  is  correct  from  an  anatomical  point  of  view,  it  is  not  the  less  ro 
that  the  practitioner  is  greatly  aided  in  prognosis  and  treatment  by  a  recog- 
nition of  the  difference  between  the  two  forms  of  tumors  just  described; 
and  also  of  that  which  exists  between  them  and  another,  which,  being 
composed  of  both  cystic  and  solid  elements,  receives  the  name  of  compound. 
"We,  therefore,  proceed  to  consider  the  varieties  of  these  growths  in  refer- 
ence to  the  points  mentioned,  and  to  recapitulate  succinctly  what  has  been 
already  said. 

Ovarian  cysts  are  characterized  by  three  marked  features :  first,  cysts 
with  one  or  very  few  large  compartments;  second,  cysts  with  a  gnat 
many  small  compartments  divided  by  thin  cyst  walls  or  thick  trabecuhe  ; 
and  third,  cysts  which  are  composed  of  solid  and  fluid  elements  in  varying 


OVARIAN    CYSTS.  G85 

proportions.  The  first  constitute  the  class  styled  the  monocystic,  unilocu- 
lar, paucilocular,  or  olygocystic  tumor;  the  second,  that  known  as  the 
multilocular  or  polycystic  tumor;  and  the  third  that  which  is  commonly 
styled  the  compound  ovarian  tumor.  "  All  cystoids  are  multilocular  at 
the  commencement,"  says  ltindfieisch,  hut  unilocularization  he  declares  is 
especially  frequent  in  those  tumors  arising  from  colloid  degeneration  of 
the  Graafian  vesicles.  A  true  monocyst  is  rare,  though  it  may  grow  to 
the  size  of  the  uterus  in  the  ninth  month  of  pregnancy.  Kiwisch1  has 
met  with  one  whose  contents  weighed  over  forty  pounds.  In  the  com- 
pound tumor,  cysts  having  formed  in  the  solid  tissue,  the  presence  of  solid 
and  fluid  elements  is  detected  by  examination.  These  cysts  result  chiefly 
from  softening  of  tissue,  or,  as  it  is  expressed,  by  liquefaction.  "  As  soon," 
says  Billroth,  "  as  the  new  formation  has  separated  into  sac  and  fluid  con- 
tents, in  some  cases  a  secretion  from  the  inner  wall  of  the  sac  begins,  so 
that  the  cyst  from  liquefaction  becomes  a  secretion  or  exudation  cyst  and 
thus  grows." 

Dr.  Noeggerath  has  been  led  to  assume,  by  his  microscopical  investiga- 
tions, that  "  the  proliferating  cystoma,  or  adenoma-cylindro-cellulare,  the 
origin  of  which  is  at  the  present  time  generally  associated  with  the  for- 
mation of  Pfliiger's  ducts,  is  to  a  large  extent  the  result  of  a  degeneration 
of  ovarian  bloodvessels. 

These  alterations  consist — 

1st.   Of  a  hyaline  degeneration  of  arteries  and  veins. 

2d.  Of  a  cell  proliferation  and  secondary  softening  of  the  media  of 
arteries. 

3d.  Of  an  endarteritis  destruens. 

4th.  Of  an  alteration  of  all  the  elements  constituting  the  large  arterial 
sinuses,  and  secondary  enlargement  of  the  same. 

5th.   Of  a  metamorphosis  of  capillaries  into  epithelial  tubes." 

The  walls  of  ovarian  cysts  consist  of  a  covering  of  peritoneum,  the 
proper  tunic,  tunica  albuginea,  of  the  ovary,  and  an  epithelial  layer. 
The  peritoneum  sometimes  undergoes  great  hypertrophy,  in  rare  cases 
being  half  an  inch  thick. 

The  size  to  which  ovarian  cysts  will  grow  is  truly  wonderful.  It  has 
been  already  stated  that  unilocular  or  monocystic  tumors  are  rarely  seen 
of  very  great  size,  but  instances  are  on  record  of  multilocular  tumors  con- 
taining over  one  hundred  pounds  of  fluid,  and  Dr.  Copland,  in  the  Diet. 
of  Pract.  Med.  tells  of  an  instance  in  which  five  hundred  pints  of  fluid 
were  drawn  off  by  repeated  tappings,  in  twelve  months. 

One  or  both  of  the  ovaries  may  be  affected,  the  right  being  that  most 
frequently  selected   by  the   disease.      The    comparative    frequency   with 

1  Op.  cit.,  p.  102. 


686 


OVARIAN    CYSTS. 


which   the   right  and  left  ovary  are  affected  is  shown  by  the  following 
table :— 


Authority. 

Safford  Lee    . 
Chereau    . 
Scanzoni  .     .     .     . 


No.  of  cases. 


93 

215 

41 


Right  side 
affected. 


50 

109 

14 


Left  side 
affected. 


35 

78 
13 


Both  sides. 


28 

14 


Contents  of  Ovarian  Cysts — This  subject  has  been  exhaustively  inves- 
tigated by  Soberer  and  Eischwald.1  By  the  latter  it  has  been  so  minutely 
dealt  with  that  little  is  left  to  be  desired  as  to  the  chemistry  of  such  fluids. 
These  contents  vary  very  much,  between  a  clear,  albuminous,  serous 
fluid  and  a  thick,  gelatinous  material  which  will  flow  through  no  canula, 
and  lias  to  be  manually  removed.  The  specific  gravity  may  be  as  low  as 
1007,  though  usually  it  is  1018  or  1020.  The  most  important  chemical 
constituent  is  an  albuminate,  termed  colloid,  which  is  usually  more  dense 
in  polycystic  than  olygocystic  tumors,  and  denser  in  small  olygocysts  than 
in  the  same  after  having  assumed  a  large  size.  Tapping  appears  to  increase 
the  density  of  this  fluid  in  olygocysts. 

According  to  Eischwald,  two  chemical  transformations  go  on  in  the 
fluids  of  cysts  simultaneously.  Colloid  material  changes  into  muco-pep- 
tone,  while  the  albuminates  transuding  from  the  blood  are  converted  into 
albumino-peptone.  A  species  of  digestion  of  the  raw  material  goes  on 
under  the  heat  of  the  body,  as  Rindfleisch  expresses  it,  and  consequently 
the  larger  and  older  the  tumor  the  more  fluid  are  the  contents  likely  to  be. 
Eischwald  found  these  fluids  chemically  to  consist  of  the  following  ele- 
ments : — 

Of  the  mucous  order — 

Substance  of  colloid  particles  ; 
Mucin; 

Colloid  substance ; 
Muco-peptone. 
Of  the  albuminous  order — 

Albumen  (and  fibrin)  ; 
Paralbumen ; 
Metalbumen  ; 

Albumino-peptone  (and  fibro-peptone). 
As  an  example  of  the  quantitative  analysis,  the  following  from  one  of 
Eischwald's  cases  will  serve.      1000  parts  contained — 

Water 931.96 

Organic  substances 59.77 

Debris 8.27 


1000.00 


'  YV'urzburger  Medizinische  Zeitschrift,  1864. 


CONTENTS    OF    OVARIAN    CYSTS.  G87 

The  debris  (8.27)  contained — 

Salts  soluble  in  water      .......  7.53 

Potas.  sulph COS 

"       chlor 0.59 

Sodse  nat 0.29 

"      phosph 0.16 

"      carb 0.38 

Loss 0.03 

Salts  insoluble  in  water  .......  0.74 


8.27 

Test  for  Par  albumen Leave  the  fluid  at  rest  in  a  cool  place,  filter  or 

decant,  and  thus  separate  sediment  from  supernatant  fluid.  Pass  a  stream 
of  carbonic  acid  gas  through  this  fluid,  and  instantly  a  precipitate  of  fine 
flocculi  of  paralbumen  will  occur. 

Test  for  Metalbumen Digest  another  part  of  this  fluid  with  absolute 

alcohol  for  three  days.  Filter  off  the  precipitate,  and  heat  with  distilled 
water.  Filter  again,  and  metalbumen  may  be  precipitated  by  sulphate  of 
magnesia.  Paralbumen  is  precipitated  from  this  fluid  by  a  few  drops  of 
dilute  acetic  acid  and  redissolved  by  an  excess. 

To  the  naked  eye  the  fluids  of  ovarian  cysts  present  various  appearances, 
as  they  are  tinged  with  blood  or  pus  from  hemorrhage  or  suppuration  of 
the  cyst  walls.  The  varieties  generally  met  with  are  the  following :  a 
light  colored  fluid  like  barley  water  ;  a  light  brown  fluid  like  infusion  of 
linseed ;  a  dark  red,  bloody  looking  fluid  ;  a  greenish-yellow,  semi-solid 
gelatine;  a  purulent  fluid  of  very  offensive  character  closely  resembling 
pea-soup  in  appearance  ;  very  rarely  an  intensely  black  fluid ;  and  in  der- 
moid cysts  a  grumous,  gruel-like  mass. 

Does  a  true  ovarian  cyst  large  enough  to  call  for  surgical  interference, 
that  is  to  say,  larger  than  the  size  of  a  child's  head  to  which  hydrops  fol- 
liculorum  sometimes  attains,  ever  contain  fluid  free  from  albumen  ?  This 
is  evidently  a  question  of  a  great  deal  of  importance.  Wells1  and  Barnes 
make  three  groups  of  ovarian  fluid,  the  first  of  which  they  declare  are  de- 
void of  fat  and  albumen.  "  Heat  and  nitric  acid,"  says  the  former,  "will 
neither  coagulate  nor  precipitate  them."  W.  L.  Atlee  relied  upon  absence 
of  albumen  as  a  sign  that  a  cyst  is  not  ovarian,  and  the  following  interest- 
ing case  reported  by  J.  L.  Atlee2  will  show  the  estimation  in  which  this 
point  is  held  by  him. 

"  I  operated  upon  Mrs.  M.,  aged  over  fifty  years,  in  October,  1870.  She 
had  labored  under  abdominal  enlargement  from  the  presence  of  a  fluid  for 
several  years,  and  had  been  tapped  about  twenty-seven  times,  filling  rapidly 
after  each  operation.  After  the  last  two  or  three  tappings  a  small  tumor 
remained  in  the  right  iliac  and  pelvic  regions  ;  but  at  no  time  could  albu- 

1  Dis.  of  Ovaries,  Am.  ed.,p.  92. 

2  Essay  by  Dr.  Drysdale,  Trans.  Ainer.  Med.  Asso. 


688  OVARIAN    CYSTS. 

men  be  detected  in  the  fluid  by  the  ordinary  tests  of  heat  and  nitric  acid  ; 
hence  I  diagnosed  the  case  to  be  one  of  serous  cyst  attached  to  the  broad 
ligament.  The  presence  of  the  tumor,  as  large  as  a  turkey's  egg,  in  the 
right  iliac  region,  an  unusual  thing  in  serous  cysts,  cast  a  doubt  as  to  its 
true  character  ;  but  the  inability  to  detect  albumen  by  the  above  tests  de- 
cided me  against  the  operation,  and  the  patient  was  sent  home.  Under 
these  circumstances,  a  portion  of  the  fluid  obtained  from  the  last  tapping 
was  sent  to  Dr.  Drysdale,  who  gave  a  very  decided  opinion  that  the  fluid 
was  from  an  ovarian  cyst.  Upon  the  strength  of  this  opinion  I  told  the 
friends  of  the  patient  that  I  would  operate  if  she  filled  again. 

'•Accordingly,  on  the  14th  of  October,  1870,  I  removed  a  cyst  weighing 
with  the  contained  fluid,  fifteen  pounds,  and  of  an  unusual  character.  The 
upper  half  of  the  cyst  was  very  thin  and  of  a  serous  nature.  Below  the 
umbilicus  the  cyst  was  much  thicker,  and,  descending  to  the  pelvis,  proved 
to  be  the  right  ovarium,  having  one  large  cyst  filling  the  abdomen  above, 
with  an  aggregation  of  very  small  cysts  constituting  the  iliac  and  pelvic 
tumor. 

"The  peculiarity  of  this  case  consisted  in  the  rupture,  probably  at  an 
early  period  of  the  disease,  and  before  I  saw  her,  of  the  tunica  propria,  or 
albugineous  coat  of  the  ovary,  leaving  the  peritoneal  covering  intact,  and 
of  sufficient  strength  to  retain,  not  only  the  small  portion  of  the  ovarian 
secretion,  but  of  the  serum  secreted  by  the  peritoneal  coat.  This  also  ac- 
counted, in  some  measure,  for  the  very  rapid  filling  after  each  tapping." 

The  correctness  of  the  explanation  given  by  Dr.  Atlee  is  open  to  doubt, 
but  his  reliance  upon  presence  of  albumen  as  a  sign  of  ovarian  cyst  is  fully 
shown.  Peaslee1  expresses  himself  in  these  words,  "  the  fluid  of  an  ova- 
rian cystoma  will  probably  always  be  found  to  contain  albumen  if  it  be 
limpid  enough  to  flow  through  the  fine  tube  of  the  exploring  trocar."  I 
can  safely  say  that  I  have  never  met  with  a  true  ovarian  fluid  which  did 
not  contain  albumen. 

The  solid  elements  of  the  fluid  of  ovarian  cysts  consist  of  the  results  of 
hemorrhage,  and  desquamation  and  fatty  degeneration  of  epithelial  struc- 
tures. In  them  are  found  cholesterine,  fat  globules,  blood  corpuscles,  and 
pigment  cells. 

Microscopical  Appearance  of  Ovarian  Fluids. — The  thinner,  serous 
fluids  present  in  comparison  with  those  of  colloid  character  few  cellular 
elements.  In  the  latter,  under  a  power  of  from  300  to  5o0  Eischwald2 
found  such  an  amount  of  morphological  elements  that  the  fluid  had  to  be 
diluted  with  water  before  it  could  be  examined.  He  then  found  fatty  ele- 
ments of  various  size ;  round  cells,  some  serrated ;  large,  colloid  cells ; 
round  cells  similar  to  the  pyoid  bodies  of  Lebert,  or  the  exudative  cor- 
puscles of  Henle ;  globular  aggregations  varying  in  size ;  scales  of  horny 
epithelium;  crystals  of  cholesterine  ;  dark  brown  pigment ;  etc. 

"On  placing  a  drop  of  the  fluid  removed  from  an  ovarian  cyst  under  the 
microscope, "  says  Drysdale,3  "  we  usually  find  a  number  of  granular  cells, 

'  Op.  cit.,  p.  110.  -  Op.  cit.  8  Op.  cit. 


CONTENTS    OF    OVARIAN    CYSTS, 


G89 


E,  some  free  granular  matter,  C,  and  small  oil  globules,  b  ;  and  frequently, 
in  addition  to  these,  epithelial  cells  of  various  forms,  A,  and  crystals  of  cho- 
lesterinc,  D.  These,  together  with  blood-corpuscles,  F,  the  inflammatory 
globules  of  Gluge,  i,  the  pus  cells,  G  H,  and  disintegrated  blood  and  other 
cells,  may  all  be  sometime*  seen  floating  in  either  a  clear  or  a  turbid  fluid." 


Fig.  252. 


,.r§?Jr©«a  .., „ 


i:® 


<;^;: 


Microscopic  appearance  of  ovarian  fluid.     (Drysdale.) 

For  the  microscopist  and  pathologist  all  these  are  of  interest.  For  the 
ovariotomist  this  is  the  chief  point  of  importance  :  is  there  any  character- 
istic, pathognomonic  cell  or  element  upon  the  presence  of  which  a  positive 
diagnosis  of  ovarian  cyst  may  be  based?  When  this  question  can  be  un- 
reservedly answered  in  the  affirmative,  a  great  advance  will  have  been 
made  in  this  important  matter.  Spiegelberg,  in  an  interesting  lecture 
upon  the  diagnosis  of  ovarian  tumors,  enumerates  cylindrical  epithelium, 
colloid  cells,  cholesterine,  etc.,  and  appears  to  rely  upon  the  character  of 
cells  furnished  by  the  part  from  which  the  material  was  secreted  rather 
than  upon  any  particular  cell. 

Long  ago,  Nunn  pointed  out  the  existence  of  the  "  gorged  granule," 
though  not  as  a  diagnostic  point,  and  Paget,  Bennett,  Gluge,  and  others 
speak  of  the  "granular  corpuscle,"  the  "  compound  granular  cell,"  and  the 
"inflammation  globules."  In  an  essay,  already  referred  to,  Dr.  T.  M. 
Drysdale,  of  Philadelphia,  has  recently  described  a  cell  which  he  calls 
"  the  ovarian  granular  cell,"  which,  when  found  in  pelvic  tumors,  he 
44 


690  OVARIAN    CYSTS. 

regards  as  pathognomonic  of  ovarian  disease,  and,  as  such,  he  looks  upon 
its  diagnostic  value  as  very  great.  This  matter  is  of  so  great  importance, 
that  I  prefer  to  describe  this  cell  in  Dr.  Drysdale's  words.  In  referring 
to  the  cells  shown  in  Fig.  252  he  says: — 

"To  find  them  all  present  in  one  specimen,  however,  is  rare;  more 
commonly  Ave  can  discover  but  three  or  four  of  them  in  the  fluid.  But  no 
matter  what  other  cells  may  be  present  or  absent,  the  cell  which  is  almost  inva- 
riably found  in  these  fluids  is  the  (jranular  cell. 

"This  granular  cell,  E,  in  ovarian  fluid,  is  generally  round,  but  sometimes 
a  little  oval  in  form,  is  very  delicate,  transparent,  and  contains  a  number 
of  flne  granules,  but  no  nucleus.  The  granules  have  a  clear,  well-defined 
outline.  These  cells  differ  greatly  in  size,  but  the  structure  is  always  the 
same.  They  may  be  seen  as  small  as  the  one  five-thousandth  of  an  inch 
in  diameter,  and  from  this  to  the  one  two-thousandth  of  an  inch.  In  some 
instances  I  have  found  them  much  larger,  but  the  size  most  commonly  met 
with  is  about  that  of  a  pus  cell. 

"The  addition  of  acetic  acid  causes  the  granules  to  become  more  distinct, 
while  the  cell  becomes  more  transparent.  When  ether  is  added  the  gran- 
ules become  nearly  transparent,  but  the  appearance  of  the  cell  is  not 
changed. 

"This  granular  cell  may  be  distinguished  from  the  pus  cell,  lymph  cor- 
puscle, white  blood  cell,  and  other  cells  which  resemble  them,  both  by  the 
appearance  of  the  cell  and  by  its  behavior  with  acetic  acid. 

"The  pus  and  other  cells,  G,  which  have  just  been  named,  have  often  a 
distinctly  granular  appearance  ;  but  the  granules  are  not  so  clearly  defined 
as  in  the  granular  cell  found  in  ovarian  disease,  owing  to  the  partial 
opacity  of  these  cells ;  and  when  the  granular  cell  of  ovarian  disease  and 
the  pus  cell  are  placed  together  under  the  microscope,  this  difference  is 
very  apparent.  In  addition  to  the  opacity  of  these  cells,  we  frequently 
find  their  cell  wall  appearing  wrinkled  rather  than  granular ;  and  further, 
in  the  fresh  state,  they  are  often  seen  to  contain  a  body  resembling  a 
nucleus. 

"But,  if  there  is  doubt  as  to  the  nature  of  the  cell,  the  addition  of  acetic 
acid  dispels  it ;  for,  if  it  is  a  pus  cell,  or  any  of  the  cells  named  above,  it 
will,  on  adding  this  acid,  be  seen  to  increase  in  size,  become  very  trans- 
parent, and  nuclei,  varying  in  number  from  one  to  four,  will  become 
visible.  (See  G,  pus  cell  before  adding  acid ;  and  II,  pus  cell  after  adding 
acid.)  Should  the  cell,  however,  be  an  ovarian  granular  cell,  the  addition 
of  this  acid  will  merely  increase  its  transparency  and  show  the  granules 
more  distinctly. 

"The  compound  granular  cell,  I,  the  granule  cell  of  Paget  and  others, 
or  inflammation  corpuscle  of  Gluge,  is  also  occasionally  present  in  these 
fluids,  and  might  possibly  be  mistaken  for  the  ovarian  granular  cell ;  but 
it  is  not  difficult  to  distinguish  them  from  each  other.  Gluge's  cell  is 
usually  much  larger  and  more  opaque  than  the  ovarian  cell,  and  has  the 
appearance  of  an  aggregation  of  minute  oil  globules,  sometimes  inclosed 
in  a  cell  wall,  and  at  others  deficient  in  this  respect.  The  granules  arc 
coarser,  and  vary  in  size,  while  the  granules  of  the  ovarian  cell  are  more 


CAUSES.  001 

uniform  and  very  small.  By  comparing  them  in  the  drawing  these  differ- 
ences will  he  apparent.  Again,  the  behavior  of  these  cells  on  the  addition 
of  ether  will  at  once  decide  the  question  ;  for,  while  the  ovarian  cell  re- 
mains nearly  unaffected  by  it,  or,  at  most,  has  its  granules  made  paler, 
the  cell  of  Glugc  loses  its  granular  appearance,  and  sometimes  entirely  dis- 
appears through  the  solution  of  its  contents  by  the  ether. 

"That  the  discovery  of  a  granular  cell  in  ovarian  fluid  is  new,  I  do  not 
assert,  as  J.  Hughes  Bennett  and  other  writers  have  described  granular 
cells  which  they  have  seen  in  these  fluids  ;  but,  with  one  exception,  their 
description  does  not  correspond  with  the  ovarian  granular  cell.  Bennett,1 
for  instance,  states  that  the  granular  cell  which  he  saw  exhibited  a  distinct 
nucleus  on  the  addition  of  acetic  acid,  which  is  not  the  case  with  this. 
Other  writers  have  described  the  cells  which  they  found  as  pus  and  pyoid 
cells  ;  and  yet  others  confound  them  with  the  compound  granular  cell,  or 
inflammation  globules.  The  exception  referred  to  above  is  found  in  Beale  \s 
description  of  the  microscopic  appearance  of  ovarian  fluid."2 

The  description  given  by  Beale  he  declares  to  correspond  closely  to 
that  of  his  "ovarian  granular  cell,  hut  it  is  incomplete,  and  no  test  is 
given  by  which  to  distinguish  it  from  other  granular  cells."  Dr.  Drys- 
dale,  therefore,  claims  to  have  been  the  first  to  describe  a  cell  which  has 
never  been  accurately  described  before,  and  to  have  given  the  tests  by 
which  it  may  be  distinguished  from  others,  such  as  the  pus  cell,  the  white 
blood  corpuscle,  and  the  compound  granule  cell,  which  closely  resembles 
it.     He  sums  up  in  these  words : — 

"I  claim,  then,  that  a  granular  cell  has  been  discovered  by  me  in  ovarian 
fluid,  which  differs  in  its  behavior  with  acetic  acid  and  ether  from  any 
other  known  granular  cell  found  in  the  abdominal  cavity,  and  which,  by 
means  of  these  reagents,  can  be  readily  recognized  as  the  cell  which  has 
been  described ;  and,  further,  that  by  the  use  of  the  microscope,  assisted 
by  these  tests,  we  may  distinguish  the  fluid  removed  from  ovarian  cysts 
from  all  other  abdominal  dropsical  fluids/'3 

Microscopists  are  by  no  means  agreed  as  to  the  validity  of  Drysdale's 
corpuscles  as  pathognomonic  of  ovarian  cyst.  Indeed  I  may  say  that,  so 
far  as  my  knowledge  goes,  a  very  general  scepticism  with  regard  to  it 
prevails.  Time  will  soon  settle  this  matter,  which  as  yet  cannot  be  re- 
garded as  at  rest,  for  the  subject  is  now  receiving  the  attention  which  it 
long  ago  deserved. 

Causes Very  little  is  positively  known  upon  this  subject.  The  pre- 
disposing causes  which  are  generally  admitted  are  the  following: — 

•  Ed.  Med.  and  Surg.  Journ.,  vol.  lxv.  p.  280,  1S46. 

2  The  Microscope  in  its  Application  to  Practical  Medicine.  By  Lionel  S.  Beale, 
M.B.,  F.R.S.,  etc.     3d  edit.,  p.  179. 

3  The  views  of  Dr.  Drysdale  are  not  yet  verified.  The  matter  is  at  present  sub 
j  ud  ice. 


092  OVARIAN    CYSTS. 

Age; 
Childbearing ; 

Chlorosis  ; 

Scrofulous  diathesis ; 

Menstrual  disorders ; 

Depreciation  from  poor  living. 
It  should  be  borne  in  mind  that  even  as  to  some  of  these  there  is  doubt 
and  variance  of  opinion  among  gynecologists. 

The  great  predisposing  cause  is  age,  the  affection  commonly  showing 
itself  during  the  period  of  ovarian  activity,  and  very  generally  during 
that  of  the  most  vigorous  activity.  It  is  rare  under  twenty  and  over  fifty, 
the  most  common  period  of  its  occurrence  being  between  twenty  and  forty. 
It  may,  however,  occur  in  infancy,  and  as  late  as  eighty.  A  case  has 
recently  been  recorded  in  which  ovariotomy  was  successfully  performed 
upon  a  child  of  six  years  of  age.1 

Scanzoni  records  97  cases,  70  of  which  were  from  18  to  40. 
Chereau       "      230      "    133         "  "  17  to  37. 

Lee  "      135      "      82         "  "  20  to  40. 

Of  Scanzoni's  cases  five  were  between  fifty-five  and  sixty;  of  Lee's  one 
hundred  and  thirty-five  cases,  eighty-eight  were  married,  thirty-seven  un- 
married, and  eleven  widows. 

The  much  greater  frequency  of  the  disease  among  women  who  have 
become  enfeebled  by  hard  labor,  poor  diet,  or  depressing  surroundings, 
than  among  those  better  circumstanced,  must  have  struck  every  one  of 
large  experience. 

The  uncertainty  existing  as  to  the  exciting  causes  is  even  greater  than 
this.  All  those  influences  which  theoretically  would  be  likely  to  excite 
cystic  growth,  as  ovaritis,  blows,  checking  of  menstruation,  excess  of  co- 
ition, libidinous  desires  without  gratification,  have  been  advanced  by 
authors  as  scientific  certainties.  But  proof  is  wanting,  however  plausible 
the  theoretical  reasoning  appears,  and  they  cannot  in  the  present  state  of 
science  be  admitted.  In  the  great  majority  of  cases  these  tumors  develop 
in  women  who  have  led  rational  and  quiet  lives,  in  whom  no  prejudicial 
influence  can  be  discovered  as  having  existed,  and  who  have  detected  the 
growth  of  the  tumor  when  imagining  themselves  in  very  fair  health. 

Certainly  nothing  can  with  safety  be  assumed  beyond  this,  that  it  is 
probable  that  those  influences  which  keep  up  and  intensify  ovarian  con- 
gestion, and  interfere  with  rupture  of  the  follicles  of  De  Graaf,  tend  to 
produce  cystic  and  follicular  degeneration.  Kiwiscli,  Rokitansky,  and 
Rindfleisch  all  agree  in  thinking  it  probable  that  inflammation  affecting 
the  walls  of  the  vesicles  has  an  influence  on  the  production  cf  the  disease. 

1  Med.  Press  and  Circular,  March  26,  1873. 


NATURAL    HISTORY.  003 

Natural  History  of  Ovarian  Cysts. — Ovarian  cystic  tumors  develop  cither 
by  one  or  by  a  number  of  cysts.  In  the  first  case  the  cyst  may  become  fully 
distended  by  fluid,  reach  a  point  where  its  growth  ceases  and  remain  qui- 
escent, only  annoying  the  patient  by  the  mechanical  results  of  its  presence 
and  the  appehension  that  it  may  increase  and  create  trouble.  There  are 
no  grounds  for  doubting  the  evidence  that  such  tumors  may  remain  with- 
out increase  for  even  forty  or  fifty  years,  but  such  cases  are  rare  exceptions 
to  a  general  rule.  "  Much  mischief  has  resulted,  however,"  says  Hewitt, 
"  from  looking  on  such  cases  as  the  typical  ones,  while  the  large  majority 
of  the  cases,  the  end  of  which  is  naturally  death  in  a  much  shorter  time, 
have  been  considered  as  the  exceptional  ones." 

We  now  and  then  meet  with  pulmonary  tuberculosis  which  goes  on  to 
formation  of  a  large  cavity,  and  then  for  some  unaccountable  reason  ceases 
to  advance.  The  cavity,  which  is  distinctly  discernible,  remains  quies- 
cent, and  the  patient  may  live  for  years.  As  this  is  an  exception  to  a 
rule  in  the  natural  history  of  phthisis,  so  is  the  tardy  course  of  ovarian 
dropsy  just  alluded  to  an  exception  to  the  usual  course  of  that  affection. 
The  olygocystic  tumor  grows  much  more  slowly  than  the  polycystic,  and 
this  is  the  more  marked  as  it  approaches  the  monocystic  type.  I  removed 
one  which  had  been  under  my  own  observation  for  nine  years,  and  only 
at  the  end  of  this  time  did  its  existence  affect  the  constitution. 

If  its  type  be  multilocular,  the  tumor  advances  more  rapidly,  certainly, 
and  uncontrollably,  than  in  the  case  just  mentioned.  The  prognosis  of 
ovarian  dropsy  not  interfered  with  by  art,  and  by  this  we  mean  surgical 
art,  as  medicine  has  no  controlling  or  curative  power  in  the  disease,  is 
always  unfavorable.  The  average  duration  of  the  cases  of  both  types  is 
supposed  by  the  best  modern  authorities  to  be  about  three  years  of  life 
after  the  inception  of  the  affection. 

Mr.  Safford  Lee  has  collected  statistics  as  to  the  duration  of  the  disease 
in  123  cases,  not  subjected  to  any  curative  surgical  treatment. 

In  38  the  duration  was  ......  1  year. 

"  25  "  "  "  .  .         .         .  .         .  2  years. 

"  17  "  "  " 3     " 

"  10  "  "  " 4     " 

"    4  "  "  " 5     " 

"    5  "  " 6     " 

"    4  li  "  " 7     " 

"    3  "  " 8     " 

"  17  "  "  " 9  to  50     " 

From  this  it  will  be  seen  that  out  of  123  cases  80  terminated  within 
three,  and  94  within  five  years.  At  the  same  time  that  the  fact  must  not 
be  lost  sight  of  that  17  out  of  123  cases  lasted  over  nine  years,  and  that 
some,  the  number  of  which  is  not  stated,  terminated  at  the  end  of  fifty, 
it  must  not  be  accepted  as  certain  that  these  were  cases  of  true  ovarian 


694  OVARIAN    CYSTS. 

cystoma.  Experience  in  this  affection  leads  to  the  suspicion  that  these 
were  instances  of  dermoid  cysts,  or  of  some  variety  of  abdominal  tumor 
which,  while  it  closely  simulates  ovarian  cystoma,  runs  a  much  more 
benign  course. 

I  have  removed  an  undoubted  mutilocular  ovarian  cyst  which  had  lasted, 
the  evidence  in  favor  of  duration  being  medical  and  perfectly  reliable,  for 
twenty-three  years  ;  another  for  twelve  and  a  half  years ;  another  for  ten, 
and  another  for  nine  years. 

Spontaneous  Cures  of  Ovarian  Cysts. — Sometimes  nature  effects  a  cure 
in  one  of  the  following  ways.  The  cyst  may  discharge  into  the  peritoneum, 
and  absorption  occur.  Of  this  accident  Dr.  Tilt  has  collected  71  cases, 
of  which  30  recovered,  19  were  improved,  and  21  died.  I  have  met  with 
four  instances  of  such  rupture,  two  of  which  proved  fatal  by  peritonitis. 
The  cyst  walls  may  undergo  calcareous  degeneration,  which  checks  ad- 
vance. The  cyst  may  discharge  externally  by  the  abdominal  or  dorsal 
surfaces,  or  into  the  rectum,  bladder,  vagina,  or  uterus  by  means  of  the 
Fallopian  tubes.  Instances  of  the  last  occurrence  are  mentioned  by  Mor- 
gagni,  Frank,  Follin,  and  Boivin,  and  Richard  records  five  cases. 

With  reference  to  nature's  power  alone,  or  aided  by  absorbents,  to  re- 
move the  accumulated  fluid,  Kiwisch  declares,  "We  must  express  our  dis- 
sent from  the  opinion  of  those  practitioners  who  assume  that  an  ovarian 
cyst  can  be  completely  removed  by  simple  absorption.  So  far  as  we  know, 
this  process  has  not  been  satisfactorily  demonstrated  by  a  single  case."  It 
is  the  opinion  of  many  that  absorption  of  the  contents  of  these  cysts  does 
occur,  and  numerous  instances  are  cited  in  proof;  but,  in  these  cases,  the 
doubt  arises  whether  a  true  cystoma  ovarii  existed,  or  one  of  the  periute- 
rine cysts  which  so  closely  resemble  it. 

Diseased  Conditions  affecting  Ovarian  Cysts. — I  have  already  alluded 
to  suppurative  inflammation  of  the  cyst  walls,  which  may  occur  in  conse- 
quence of  tapping,  or  without  operative  interference.  The  pulse  and 
temperature  become  elevated,  the  patient  restless  and  depressed,  profuse 
perspirations  occur,  diarrhoea  sets  in,  and,  unless  relieved,  the  patient  dies 
with  hectic  symptoms.  In  a  number  of  instances  ovariotomy  has  been 
successfully  performed  under  these  circumstances.  One  such  case  is  re- 
corded by  Keith,  the  suppurative  action  occurring  seven  days  after  tap- 
ping ;  three  by  Wells  ;  one  by  Peaslee  ;  and  one  by  Teale.1  I  have  seve- 
ral times  operated  upon  cases  in  which  ovariotomy  was  undertaken  only  as 
a  last  resort,  where  the  contents  of  the  cysts  were  excessively  fetid,  and  the 
patient  very  ill  at  the  time  of  the  operation,  and  which  have  nevertheless 
done  well. 

Twisting  of  the  pedicle  is  another  accident  which  sometimes  takes 
place.     Gallez,2  in  referring  to  this,  says,  "This  very  curious  and  happy 

1  London  Lancet,  Am.  reprint,  Sept.  1873. 

2  L.  fiallez,  Histoire  des  Kystes  de  l'Ovaire,  Bruxelles,  1873,  p.  150. 


METHODS  IN  WHICH  DEATH  IS  PRODUCED.       695 

termination  of  ovarian  cysts  is  unfortunately  very  rare,  and  likewise  very 
difficult  of  artificial  accomplishment;  its  effect  is  to  produce  strangulation 

of  the  tumor."  Where  the  interference  thus  established  in  the  vascular 
supply  of  the  tumor  goes  just  far  enough  to  produce  gradual  atrophy,  cure 
may  be  effected,  and  post-mortem  evidence  of  such  an  occasional  occur- 
rence exists.  Ordinarily  strangulation  and  death  of  the  tumor  occur, 
which  destroy  life  unless  ovariotomy  should  intervene.  In  18(35  Koki- 
tansky  published  an  essay  upon  this  subject,  and  since  that  time  it  has 
attracted  considerable  attention.  He  cited  the  details  of  thirteen  cases, 
and  Spencer  Wells  mentions  two  deaths  thus  caused  before  operation,  and 
twelve  cases  discovered  by  him  upon  performance  of  ovariotomy.  Klob 
reports  an  instance  in  which  a  tumor  turned  upon  its  pedicle  five  times; 
and  in  a  case  of  fatal  hemorrhage  into  the  cyst  Patruban  found  in  autopsy 
torsion  of  the  pedicle  creating  venous  stenosis  and  rupture.1  Crane2  and 
Tait3  record  cases  in  which  small  cysts  were  thus  rendered  gangrenous,  in 
consequence  of  which  the  patients  died  of  septicaemia. 

Sometimes  an  ovarian  cyst  increases  very  suddenly  in  dimensions,  great 
pain  from  distention  occurs,  and  symptoms  of  loss  of  blood  develop  them- 
selves. This  is  due  to  hemorrhage  from  the  cyst  wall.  In  two  cases  in 
my  experience  it  has  occurred ;  in  one  ovariotomy  demonstrated  the 
source  of  the  difficulty;  and  in  the  other  aspiration,  adopted  on  account  of 
the  severe  suffering  from  distention,  did  so.  Parry4  records  a  case  which 
almost  proved  fatal  from  this  cause,  and  Patruban5  one  which  did  so.  In 
the  latter  case  torsion  of  the  pedicle  seemed  to  have  produced  the  rupture 
of  vessels.  Wonder  at  such  an  occurrence  will  cease  when  it  is  remem- 
bered that  veins6  as  large  as  the  little  finger  have  been  found  between  the 
outer  and  middle  layer  of  cysts. 

Conditions  likely  to  complicate  Ovarian  Cysts They  may  be  compli- 
cated by  pregnancy;  ascites;  fecal  impaction;  Bright's  disease;  pleuritic 
effusion  ;  peritonitis  with  adhesions  ;  a  low  type  of  gastritis  marked  by 
intensely  red  tongue,  constant  vomiting,  and  tenderness  of  the  stomach ; 
a  low  grade  of  septicaemia  ;  diarrhoea  ;  inguinal,  umbilical,  and  crural 
hernia,  etc. 

Methods  in  which  Death  is  produced There  are  several  modes  in  which 

ovarian  dropsy  produces  its  usual  fatal  results  when  uninterfered  with  by 
surgical  means. 

1st.  A  cyst  may  rupture  and  produce  peritonitis,  either  before  or  after 
suppurative  inflammation  of  its  walls. 

2d.  Inflammation  of  the  cyst  wall  may  result  in  the  filling  of  the  cyst 
with  pus,  which  produces  hectic  and  in  time  exhaustion  and  death. 

1  London  Lancet,  Am.  reprint,  Sept.  1ST3. 

2  Amer.  Med.  Monthly,  April,  18(31.  3  Edin.  Med.  Journal,  18(31. 
4  Am.  Journ.  Obstet.,  Nov.  1871.                       *  Gallez,  op.  cit.,  p.  150. 

6  T.  S.  Lee. 


G96  OVARIAN    CYSTS. 

3d.   Fatal  hemorrhage  may  occur  into  the  cyst. 

4th.  Prolonged  interference  with  the  functions  of  nutrition  and  respira- 
tion may  sap  the  powers  of  life. 

oth.  Death  of  the  cyst  may  occur  from  twisting  or  rupture  of  the  pedi- 
cle and  cause  septicaemia. 

6th.  A  low  grade  of  gastritis,  pleuritis,1  or  enteritis  may  produce  ex- 
haustion. 

7th.  Finally,  from  the  combined  depreciating  influences  of  this  condi- 
tion, gradual  or  sudden  prostration  of  strength  may  close  the  scene  by 
death. 

Every  one  having  charge  of  a  case  of  ovarian  tumor  should  recollect 
that  often  the  only  hope  of  saving  life,  threatened  by  the  accidents  here 
recorded,  consists  in  an  immediate  resort  to  ovariotomy.  Even  acute 
peritonitis  has  been  thus  cut  short,  and  patients  with  a  temperature  of  105° 
from  suppuration  of  the  sac  have  been  saved.  Spencer  Wells  arrived  just 
too  late  to  save  two  cases  in  which  death  resulted  from  hemorrhage  into  the 
sac,  and  Wiltshire  in  time  to  save  one,  and  I  operated  with  a  successful 
result  in  a  patient  nearly  completely  collapsed  from  sudden  rupture  of  a 
large  cyst. 

We  now  approach  the  important  subject  of  symptomatology  of  ovarian 
cysts  and  their  differentiation  from  other  morbid  conditions  met  with  in 
the  abdomen.  As  the  study  of  that  subject  will  frequently  involve  allu- 
sion to  pelvic  cysts  closely  resembling  ovarian  but  yet  entirely  distinct 
from  the  ovaries,  I  deem  it  best  to  take  a  rapid  survey  of  them  here. 

Cysts  of  the  Broad  Ligaments. — Cysts  of  considerable  size  sometimes 
form  between  the  layers  of  peritoneum  making  up  the  envelopes  of  the 
broad  ligaments.  They  are  supposed  to  arise  from  the  collection  of  fluid 
in  the  meshes  of  areolar  tissue  of  the  ligaments,  or  from  the  parovaria  or 
bodies  of  Rosenmuller.  Within  the  external  margin  of  the  broad  liga- 
ment, where  the  two  walls  of  the  peritoneum  pass  from  the  fimbria?  of  the 
tube  to  the  ovary,  exists  the  body  of  Rosenmuller,  parovarium,  or  Wolffian 
body,  to  which  allusion  has  already  been  made  as  consisting  of  a  number 
of  little,  tortuous  cords,  some  of  which  are  perforated  by  canals.  The 
slight  secretion  occurring  from  the  walls  of  these  tubes  sometimes  becomes 
greatly  increased,  and  the  containing  walls  becoming  proportionately  dis- 
tended, a  tumor  is  created.  These  cysts  may  attain  a  large  size,  though 
they  do  not  generally  do  so. 

One  of  the  most  interesting  cases  of  cyst  of  the  broad  ligament  which  I 
have  seen  in  practice  was  in  a  lady  from  Mobile,  upon  whom  ovariotomy 
was  successfully  performed  by  the  late  Dr.  Nott,  of  this  city.  He  had 
tapped  her,  and  drawn  off  a  large  amount  of  limpid  fluid  four  years  before 

1  I  have  seen  two  cases  in  which  hydrothorax  proved  a  great  source  of  prostra- 
tion. 


TUBAL    DROPSY.  697 

the  operation,  and  the  cyst  had  for  about  three  years  appeared  to  have 
closed.  After  that  time,  however,  it  had  refilled,  and  was,  when  I  first 
saw  her  in  consultation  with  Dr.  Nott,  quite  tense,  and  the  abdomen  ap- 
peared of  about  the  size  of  that  of  a  woman  in  the  seventh  month  of  preg- 
nancy. Operation  was  determined  upon,  but  delayed  for  three  months  in 
consequence  of  the  heat  of  the  weather.  "When  it  was  performed,  both 
ovaries  were  found  to  be  perfect  in  size  and  shape,  and  the  cyst1  was  found 
to  occupy  the  left  broad  ligament,  the  peritoneal  walls  of  which  were  im- 
mensely distended  over  its  surface. 

The  peculiar  features  which  have  been  found  to  characterize  cysts  of  the 
broad  ligaments  are  the  following:  They  contain  a  clear,  limpid,  very 
slightly  albuminous  liquid,  which  takes  on  a  purplish  tinge  when  exposed 
to  the  rays  of  the  sun  ;  tapping  generally,  though  not  always,  cures  them ; 
after  tapping  no  cyst  can  be  felt ;  they  are  always  unilocular ;  and  they 
have  been  found  to  contain  in  their  walls  nonstriated  muscular  fibre,  which 
the  walls  of  ovarian  cysts  never  contain. 

Parasitic  or  Hydatid  Cysts Although  cases  of  these  cysts,  developed 

in  consequence  of  the  presence  of  the  echinococcus  hominis  and  cysticercus 
cellulosfe,  are  reported  as  having  occurred  in  the  ovaries,  it  is  doubtful 
wdiether  such  reports  are  authentic.  These  parasites  may,  however,  de- 
velop in  the  mesentery,  the  omentum  majus,  and  even  in  the  cellular  tis- 
sue ;  the  vesicle  of  which  the  parasite  consists  becoming  surrounded  by  a 
neoplastic  sac.  "I  have  seen,"  says  Billroth,  "cysticercus  vesicles  re- 
moved from  the  tongue  and  nose,  echinococcus  vesicles  removed  from  the 
back  and  thigh."  Spiegelberg  reports  a  case  of  retro-uterine,  left  sided 
parasitic  cyst,  simulating  ovarian  cyst,  in  which  he  cut  down  and  removed 
some  of  the  characteristic  contents.  This  procedure  and  tapping  or  aspi- 
ration are  the  only  means  of  diagnosis  which  are  at  all  reliable. 

Tubal  Dropsy — This  condition,  which  is  described  under  the  names, of 
hydrops  tuba?,  salpingian  dropsy,  and  hydrosalpinx,  consists  in  the  disten- 
tion of  the  Fallopian  tubes  by  muco-serous  fluid It  arises  in  this  manner: 

some  influence,  for  example,  acute  or  chronic  salpingitis,  pelvic  peritonitis, 
or  cellulitis,  occludes  both  extremities  of  the  tube.  The  inflammation  of 
the  mucous  membrane  of  the  tube  creating  a  muco-serous  fluid,  the  canal 
is  distended  by  this,  generally  irregularly,  to  the  size  of  the  finger  or  small 
intestine.  Thus  far  the  affection  does  not  concern  our  present  investiga- 
tion, for  there  is  no  probability  that  such  a  growth  would  resemble  ovarian 
tumor  so  closely  as  to  lead  to  an  error  in  diagnosis.  But  as  this  distention 
goes  on,  the  mucous  lining  of  the  tube  takes  on  the  anatomical  and  phy- 
siological characters  of  a  serous  membrane,  and  secretes  plentifully  a  serous, 
straw-colored,  and  slightly  flocculent   fluid.     At  times  the  distention  of 

1  This  cyst  is  now  in  my  possession.  Dried  and  stuffed  with  cotton,  it  measures 
26  inches  in  circumference. 


698  OVARIAN    CYSTS. 

the  walls  of  the  tube  proceeds  so  far  that  the  fluctuating  tumor  which 
results  gives  all  the  physical  signs  of  ovarian  dropsy. 

The  testimony  of  authorities  is  almost  unanimous  that  between  this  con- 
dition and  ovarian  dropsy  there  are  no  means  of  diagnosis  without  with- 
drawal of  some  of  the  fluid.  M.  Aran  sounds  the  key-note  to  the  general 
belief  when  he  declares  that,1  "  the  tube  distended  by  liquid,  I  am  per- 
fectly assured,  does  not  give  a  sufficiently  clear  sensation  to  allow  us  to 
diagnosticate  its  existence."  Prof.  Simpson,  however,  assumes  a  different 
position.2  He  declares  that,  although  "  in  practice  this  form  of  tumor  is 
usually  altogether  overlooked  or  is  mistaken  for  some  other  kind  of  tumor," 
it  is  really  diagnosticable  by  the  following  means  :  "  1st,  its  free  and  inde- 
pendent mobility  ;  2d,  its  elongated  form ;  and  3d,  its  wavy  outline."  Let 
any  one  examine  the  shape  of  a  large  tubal  dropsy,  like  that  represented 
at  Fig.  253,  for  instance,  and  he  will  see  that  both  the  shape  and  wavy 

Fig.  253. 


Tubal  dropsy.     (Hooper.) 

outline  will  fail  him.  "When  it  is  remembered  that  the  affection  frequently 
results  from  pelvic  peritonitis,  it  will  be  apparent  that  the  freedom  of  mo- 
tion will  be  often  delusive.  "  The  diseased  tube,"  says  Courty,3  "  is  rarely 
free  and  without  alteration  at  its  periphery:  generally  it  bears  signs  of  old 
inflammation,  which  is  adhesive,  and  this  fixes  it  to  the  neighboring  parts." 
I  have  met  with  the  affection  four  or  five  times  in  autopsies,  and  this 
statement  has  always  been  sustained. 

The  means  of  diagnosis  just  mentioned  would  be  applicable  to  slight 
tubal  distention,  which  is  rarely  productive  of  symptoms  calling  for  ex- 
amination. Few  instances  of  diagnosis  are  on  record,  and  even  in  cases 
where  tapping  has  been  supposed  to  substantiate  it,  it  is  by  no  means  sure 
that  such  a  disease  existed.  Prof.  Simpson  reports  but  one  case  in  his 
extensive  experience  in  which  he  was  able  to  come  to  a  conclusion.  He 
denies  the  possibility  of  great  enlargement  of  these  tumors,  declaring  that 
they  rarely  grow  larger  than  a  fuetal  head,  and  that  we  may  justly  be 
allowed  to  be  sceptical  as  to  cases  reported  as  being  much  larger.     Dr. 

'  Op.  cit.,  p.  G33.  2  Op.  cit.,  p.  432.  8  Op.  cit.,  p.  987. 


SYMPTOMS.  690 

Arthur  Farre,1  however,  willingly  admits  the  well-known  cases  of  Bonnet 
and  De  Haen  ;  the  first  of  which  contained  thirteen  pounds  of  fluid  and 
the  second  thirty-two  pounds.  Scanzoni  circumstantially  reports  an  in- 
stance in  which  the  sac  attained  the  size  of  the  head  of  a  child  of  ten  years 
of  age. 

Subperitoneal  Cysts Cystic  degeneration  is  much  more  likely  to  occur 

in  those  organs  which  have,  as  component  parts  of  their  structure,  minute 
cavities  lined  by  epithelium.  Thus,  the  kidneys  and  ovaries  are  pecu- 
liarly liable  to  be  affected  in  this  way.  Cysts  thus  formed  have  been 
styled  by  Yirchow  cysts  by  retention.  But  cystic  degeneration  is  by  no 
means  limited  to  such  structures.  It  may  occur  in  areolar  tissue  any- 
where, and  those  organs  which,  like  the  thyroid  and  mammary  glands, 
are  prone  to  production  of  new  growths  having  areolar  tissue  as  their 
basis,  are  likewise  especially  liable  to  it. 

It  is  believed  by  pathologists  that  under  these  circumstances  the  cyst  is 
merely  an  expansion  of  the  areola}  of  the  areolar  tissue.  In  various  parts 
of  the  abdominal  cavity  such  cysts  are  found  under  the  peritoneum  and 
classed  under  the  head  of  subperitoneal  cysts.  Mr.  Safford  Lee  reports 
one  case  of  a  tumor  which  filled  the  abdomen,  and  destroyed  life,  after 
having  lasted  for  twenty-five  years.  On  post-mortem  inspection  a  large 
cyst  was  found  behind  the  peritoneum,  which  had  originated  under  the 
pancreas.  He  reports  another  which  began  on  the  right  side  of  the 
abdomen,  was  tapped  forty -eight  times,  and  wTas  found  by  autopsy  to  be 
omental. 

Cysts  connected  with  the  Spinal  Cord — In  November,  1870,  a  woman 
aged  86  years  entered  the  Woman's  Hospital  in  this  city,  and  came  under 
the  care  of  Dr.  Emmet.2  He  found  a  large  cyst  filling  the  hollow  of  the 
sacrum  and  there  firmly  fixed.  To  aid  in  diagnosis,  an  ounce  of  fluid  was 
drawn  oif  by  aspiration.  This  was  clear  and  limpid,  free  from  albumen, 
and  revealed  under  the  microscope  only  a  few  oil  globules.  The  patient 
died,  and  Dr.  F.  Delafield  on  making  an  autopsy  found  a  cyst,  which 
contained  some  three  quarts  of  fluid,  filling  completely  the  pelvic  cavity 
and  extending  up  to  a  level  with  the  second  lumbar  vertebra.  This  com- 
municated with  the  spinal  cord  by  a  funnel-shaped  passage,  which  had  as 
its  lower  outlet  an  oval  opening  extending  from  the  upper  margin  of  the 
second  sacral  foramen  on  the  right  to  the  position  of  the  coccyx,  which 
was  wanting.  Over  the  surface  of  the  sac  was  a  network  of  nerve  tissue, 
extending  posteriorly  and  to  the  right  side.  The  sac  was  supposed  to  be 
one  of  spina  bifida  or  hydrorachis. 

Symptoms During  the  earlier  periods  of  the  development  of  ovarian 

cysts,  very  few  symptoms  ordinarily  show  themselves.     As  enlargement 

1  Supplement  Cyc.  Anat.  and  Phys.,  p.  619. 

2  This  case  is  described  in  the  Amer.  Journal  of  Obstetrics,  Feb.  1871. 


700  OVARIAN    CYSTS. 

goes  on  the  patient  becomes  struck  by  the  fact  that  her  abdomen  has  in- 
creased in  size,  and,  if  both  ovaries  be  affected,  menstruation  sometimes 
ceases,  artd  she  may  imagine  she  has  beeome  pregnant.  Pressure  of  the 
small  but  increasing  tumor  will  sometimes  create  dragging  sensations 
about  the  pelvis,  irritability  of  the  bladder,  and,  if  the  growth  occupy  the 
retro-uterine  space,  as  it  often  does,  pain  in  the  back.  This  is,  however, 
by  no  means  all  the  inconvenience  which  may  be  experienced.  A  small, 
movable  cyst,  which  may  be  pushed  about  in  the  abdomen,  will  sometimes 
cause  severe  pain.  In  one  such  case  which  I  saw  with  Dr.  Noeggerath, 
the  account  of  which  is  published  in  Dr.  Atlee's  work  on  the  Ovaries, 
ovariotomy  was  necessitated,  when  the  cyst  was  no  larger  than  a  cocoanut, 
by  excessive  pain. 

As  the  tumor  grows  and  fills  the  abdomen,  rising  above  the  navel,  a 
sense  of  distention  is  complained  of,  dyspnoea  begins  to  show  itself  upon 
exertion,  the  patient  feels  more  feeble  than  usual,  and  slight  emaciation 
is  observed.  As  it  increases  and  begins  to  press  upon  the  large  viscera 
beneath  the  diaphragm,  these  symptoms  increase,  and  the  patient's  face 
wears  a  peculiar  expression,  which  has  been  styled  by  Mr.  Wells,  the 
"facies  ovariana.''  This  is  created  by  an  absorption  of  adipose  tissue,  an 
exaggeration  of  the  natural  furrows  of  the  face,  and  an  expression  of 
anxiety  and  apprehension.  To  one  who  has  studied  this  expression,  an 
imperfect  description  such  as  this  will  recall  it;  but  to  one  who  has  not 
become  clinically  familiar  with  it,  it  is  impossible  to  convey  a  clear  con- 
ception of  it.  To  these  symptoms  the  mammary  and  gastric  symptoms  of 
pregnancy  sometimes,  though  rarely,  add  themselves. 

Pressure  upon  the  kidneys  creates  congestion  of  these  organs,  and 
scanty  secretion  is  a  common  result.  Occasional  attacks  of  localized  peri- 
tonitis are  by  no  means  rare,  and  hence,  in  many  cases,  ascites  becomes  a 
complication  of  the  affection. 

As  the  decadence  of  strength,  the  emaciation,  and  the  impoverishment 
of  the  blood  incident  to  this  grave  disorder  increase  with  time,  digestive 
and  intestinal  disorders  show  themselves,  oedema  of  the  feet  and  legs 
occurs,  great  feebleness  appears,  and  the  patient  dies  from  progressive 
exhaustion. 

A  summary  of  the  rational  signs  which  may  arise  in  consequence  of 
ovarian  cysts  from  the  commencement  of  their  growth  to  full  development 
may  thus  be  given  ;  irritability  of  the  bladder,  dysmenorrhoea,  constipa- 
tion, hemorrhoids,  pelvic  pains  of  neuralgic  character,  symptoms  of  preg- 
nancy, scanty  urinary  secretion,  intestinal  and  digestive  disorder,  deranged 
respiratory  function,  peculiar  facies,  emaciation,  oedema,  venous  distention 
on  surface,  ascites,  vomiting,  diarrhoea,  cardiac  irregularity,  aphthous 
stomatitis,  and  hectic.  In  cases  advanced  in  the  last  stage,  all  the  last  of 
these  may  show  themselves,  and  in  early  cases,  all  the  first  mentioned  ; 


PHYSICAL    SIGN'S.  701 

but,  in  many  instances,  some  of  the  most  prominent  of  these  signs  are 
entirely  wanting. 

Physical  Signs The   symptoms   thus  far  enumerated  are  never  sutli- 

cient  for  diagnosis.  They  are  usually  only  sufficient  to  suggest  physical 
examination,  by  which  reliable  signs  will  probably  be  discovered,  and  the 
diagnosis  be  made  complete. 

The  physical  signs  of  ovarian  cysts  are,  therefore,  of  the  greatest 
importance,  and  the  full  capacity  of  physical  exploration  should  in  every 
case  be  developed,  for  to  it  we  must  look  for  answers  to  the  following 
questions : — 

1st.  Does  a  tumor  exist? 
2d.   If  so,  is  it  ovarian  ? 

Does  a  tumor  exist? — To  decide  this  question,  the  patient  should  be 
placed  upon  her  back  upon  a  flat,  resisting  surface,  the  abdomen  uncovered, 
all  constriction  removed  from  the  waist,  and  the  knees  drawn  up  so  as  to 
relax  the  abdominal  muscles.  It  is  of  primary  importance  that  she  should 
be  calm,  and  give  herself  up  to  the  examination  in  the  full  desire  of  aid- 
ing the  physician  in  arriving  at  a  diagnosis.  In  some  cases  the  patient, 
from  nervousness,  in  some  from  pain  created  by  pressure,  and  in  others 
from  a  desire  to  mislead  and  deceive,  will  not  be  able  or  willing  to  do  this, 
but,  by  suddenly  contracting  the  abdominal  walls,  will  place  a  serious, 
perhaps  insurmountable,  obstacle  in  his  way.  Under  such  circumstances 
ether  should  be  employed  as  an  anaesthetic,  and  full  investigation  made. 
The  abdominal  muscles  being  entirely  relaxed,  careful  palpation  and  deep, 
steady,  and  prolonged  pressure  should  be  made  by  both  hands  over  the 
whole  abdomen,  downwards  towards  the  spine,  and  especially  over  the  pel- 
vic region.  By  this  means  a  more  or  less  resisting  mass  may  be  discov- 
ered, which  produces  an  abdominal  enlargement  visible  upon  inspection. 

Thus  far  very  little  has  been  learned  ;  merely  that  an  abnormal  enlarge- 
ment exists  in  the  abdomen.  It  may  not  deserve  the  significant  name  of 
tumor,  but  be  due  to  one  of  these  states  : — 

1st.  Abnormal  thickness  of  abdominal  walls; 

2d.  Tonic  spasm  of  abdominal  muscles; 

3d.  Intestinal  distention  ; 

4th.  Distention  of  urinary  bladder  ; 

oth.  Pregnancy. 
With  care  and  caution  each  of  these  conditions  may  usually  be  elimi- 
nated by  means  which  we  shall  soon  consider.     A  neglect  of  such  means 
has  often  resulted  in  great  and  needless  alarm  to  patients,  and  a  painfully 
humiliating  and  often  ludicrous  exposure  of  the  practitioner. 

It  having  been  now  decided  that  the  patient  has  an  abdominal  tumor, 
or,  in  other  words,  an  abdominal  swelling  due  to  a  morbific  cause  of 
serious  nature,  it  next  becomes  important  to  decide  whether  it  be  ovarian 
or  not. 


702  OVARIAN    CYSTS. 

Is  the  tumor  ovarian'? — It  lias  been  already  stated  that  any  abdominal 
tumor  may,  unless  careful  means  of  differentiation  are  adopted,  be  con- 
founded with  ovarian  growths.  The  truth  of  this  will  be  appreciated  by 
reference  to  the  valuable  tables  of  Dr.  John  Clay,  the  translator  of  Kiwisch 
on  the  Ovaries.  He  has  collected  twenty-three  cases  of  attempted  ovari- 
otomy in  which  the  operation  was  abandoned  because  the  tumor  proved 
not  to  be  ovarian.  The  tumors  were  of  the  following  characters: — 
12  were  uterine ; 
2     "     omental ; 

2     "     results  of  chronic  peritonitis  ; 
2     "     not  discoverable ; 
1   was  tubal  pregnancy  ; 
1     "     obesity; 
1     "     mesenteric ; 
1     "     splenic ; 
1     "     not  stated. 
So  great  did  the  difficulties  of  diagnosis  for  a  long  time  prove,  that  they 
were  urged  by  the  opponents  of  the  operation  as  a  valid  objection  to  it  as 
a  surgical  procedure.     At  the  same  time  that  they  are  still  acknowledged, 
and  that  it  is  admitted  that  the  most  cautious  and  skilful  diagnostician 
may  be  defeated  by  them,  it  can  be  confidently  asserted  that  every  year's 
experience  greatly  diminishes  them,  and  that  with  the  improved  means 
now  at  command,  an  experienced  examiner  will  rarely  be  misled.     Let 
me,  however,  again   insist  upon  the  fact  that  immunity  from  oft  repeated 
errors  can  be  obtained,  even  by  such  an  one,  only  by  strict  adherence  to 
a  conscientious  and  exhaustive  examination  of  every  case,  a  resort  to  all 
the  known   means  of  diagnosis,  and  a  methodical  exclusion  of  all  condi- 
tions calculated  to  mislead. 

It  is  a  fact  which  I  daily  see  demonstrated  that  an  inexperienced  diag- 
nostician usually  arrives  at  a  conclusion  by  the  application  of  a  much 
smaller  number  of  tests  than  a  veteran  examiner  would  dare  to  do.  The 
latter  has  been  so  often  deceived  that  he  knows  his  weakness;  the  former 
has  yet  to  learn. 

The  means  of  physical  exploration  which  are  at  our  disposal  are  the 
following : — 

Inspection  and  manipulation  ; 

Mensuration  ; 

Palpation  ; 

Percussion  ; 

Ausculation ; 

Vaginal  touch  ; 

Rectal  touch  ; 

The  uterine  sound ; 

Aspiration  or  paracentesis ; 


PHYSICAL    SIGNS.  703 

Chemical  and  microscopical  examination  of  fluids  of  the  tumor  ; 
Explorative  incision. 

Solid  ovarian  tumors  are  rare  and  seldom  assume  very  large  propor- 
tions, and  although  ovariotomy  is  sometimes  demanded  for  their  removal, 
the  operation  is  specially  adapted  to  cystic  tumors.  We  therefore  pass  to 
the  more  careful  consideration  of  the  diagnosis  of  these,  and  their  differen- 
tiation from  other  abdominal  enlargements. 

An  ovarian  cyst  usually  develops  markedly  on  one  side  of  the  abdomen, 
and  if  multilocular  the  abdominal  distention  is  not  symmetrical  even  in 
advanced  periods.  As  it  increases,  the  cyst  pushes  the  intestines  aside 
into  the  hypochondriac  regions.  The  ascending  and  transverse  colon  alone 
approximate  their  normal  positions,  and  the  omentum  majus  is  usually 
pushed  up  over  the  front  of  the  tumor.  While  the  cyst  is  in  the  pelvis, 
the  uterus  usually  lies  in  front  of  it,  but  as  increase  of  growth  occurs  it 
is  ordinarily  pushed  behind  it.  There  are,  however,  exceptions  to  both 
these  statements.  In  rare  cases,  fortunately  for  the  ovariotomist,  a  por- 
tion of  intestine  runs  across  the  face  of  the  tumor,  being  fixed  there  by 
adhesion.  The  uterus,  even  late  in  the  development  of  a  large  cyst,  may 
be  found  in  front  of  it  or  latero-flexed,  latero-verted,  or  even  drawn  com- 
pletely above  the  pelvic  brim.  Curious  as  it  may  appear,  great  diversity 
of  statement  exists  concerning  the  relation  of  cyst  and  uterus  among 
writers  on  this  subject.  "  Simpson's  remark,"  says  Peaslee,1  "  that,  '  if 
the  sound  show  a  tumor  in  front  of  the  uterus,  the  disease  is  certainly  not 
ovarian,'  is  incorrect.  The  uterus  is  in  front  of  an  ovarian  tumor  only  in 
exceptional  cases  ;  but  is  often  so  in  cases  of  uterine  fibroma  and  fibro-cyst. 
Boinet  mentions  the  fact  as  a  remarkable  one  that  Cruveilhier  found  the 
uterus  behind  an  ovarian  cyst  in  three  instances."  My  observation  cer- 
tainly agrees  with  that  of  Dr.  Atlee,'2  that  "  the  uterus  may  be  dragged 
up,  or  tilted  up  out  of  the  pelvic  cavity  by  the  tumor;  or,  through  these 
influences,  it  may  be  found  on  either  side,  or  displaced  forward  or  back- 
ward within  frhe  pelvis.  It  may  also  be  crowded  downward  against  the 
perineum,  or  entirely  extruded  through  the  vulvar  orifice.  So  that  there 
is  no  general  rule  as  regards  the  position  of  the  uterus  in  ovarian  tumors." 

When  the  tumor  has  ascended  above  the  umbilicus,  as  the  patient  lies 
upon  the  back,  the  abdomen  will  appear  rotund,  a  decided  protuberance 
existing,  and  very  little  flattening  out  by  sagging  of  fluid  to  the  flanks 
occurring.  As  the  hands  are  laid  upon  the  surface,  and  manipulation  is 
practised,  a  firm,  dense  mass  will  be  felt,  which  yields  fluctuation,  not 
usually  of  a  superficial  character  like  ascites,  but  less  superficial  and  per- 
ceptible. Percussion  will  yield  dulness  all  over  the  surface  of  the  tumor 
and  in  one  flank,  but  in  the  other  resonance  will  generally  exist.  The 
surface  of  the  tumor  will  often  feel  irregular  and  lobulated,  and  in  multi- 

•  Op.  cit.,  p.  115.  2  Op.  cit.,  p.  46. 


704  OVARIAN    CYSTS. 

locular  tumors  be  more  voluminous  on  one  side  than  the  other.  If  pres- 
sure be  made  upon  the  tumor,  as  the  patient  lies  upon  the  back,  it  will 
resist  like  a  full  sac,  and  not  yield,  and  the  pulsations  of  the  aorta  may  be 
felt  obscurely  through  it.  By  vaginal  and  rectal  touch  the  lower  surface 
of  the  tumor  may  be  felt  and  obscure  fluctuation  elicited. 

Mensuration  practised  from  the  umbilicus  to  the  sternum,  and  the 
umbilicus  to  the  anterior  superior  spinous  processes  of  the  ileum,  will 
generally  show  a  marked  difference  between  the  two  sides  in  polycysts 
and  less  difference  in  monocysts.  In  ascites  the  two  sides  are  symmetrical. 
Auscultation  serves  to  exclude  pregnancy.  By  vaginal  touch  the  posi- 
tion of  the  uterus  as  well  as  its  mobility  is  ascertained,  and  when  com- 
bined with  conjoined  manipulation  the  solid  or  cystic  character  of  a  small 
or  even  a  large  tumor  may  be  determined  by  it.  Should  the  tumor  be 
found  low  in  the  pelvis  in  the  later  periods  of  growth,  it  is  probable  that 
a  short  pedicle  exists,  and  also  probably  adhesions.  Should  it  have  risen 
out  of  the  pelvis  the  pedicle  is  probably,  but  by  no  means  certainly,  a 
long  one. 

The  uterine  sound  informs  us  as  to  the  capacity,  the  mobility,  and  the 
sensitiveness  of  the  uterus,  as  well  as,  to  a  limited  degree,  its  relations  to 
the  tumor. 

Simon's  method  of  rectal  exploration,  modified  by  the  introduction  of 
the  hand  without  the  thumb  into  the  bowel,  constitutes  one  of  the  most 
valuable  means  of  diagnosis  and  differentiation  at  our  command.  By  it 
the  point  of  origin  of  the  tumor,  as  well  as  its  general  characters,  may  be 
very  accurately  ascertained. 

Emptying  the  cysts  of  the  tumor  of  fluid  by  aspiration  or  tapping  is 
likewise  a  most  useful  means  of  gaining  information  ;  and  of  great  moment 
is  the  careful  and  intelligent  examination  of  the  fluids  removed. 

Of  late  it  has  been  proposed  to  determine  as  to  the  nature  of  such  fluid 
by  the  discovery  in  it  of  "luteine,"a  yellow  substance  found  in  the  blood, 
the  egg,  and  the  fluid  contents  of  ovarian  tumors.  As  yet,  this  test  has 
been  too  little  investigated  to  enable  us  to  decide  what  weight  is  to  be 
given  to  it. 

Lastly,  we  reach  the  crucial  test  of  explorative  incision,  the  value  of 
which  cannot  be  exaggerated,  but  which  is  attended  by  considerable  danger. 

These  are  the  means  by  which  the  positive  signs  of  ovarian  cystoma 
may  be  elicited,  but,  before  a  diagnosis  is  arrived  at  by  deductions  based 
upon  them,  many  other  abdominal  enlargements  must  be  carefully  con- 
sidered and  excluded.  If  this  be  necessary  merely  in  arriving  at  a  correct 
diagnosis  where  no  operation  is  to  be  practised,  how  much  more  so  is  it 
in  view  of  the  grave  procedure  of  ovariotomy.  Any  one  of  the  following 
conditions  may  mislead  the  investigator,  and  each  of  them  must  be  in 
turn  considered  by  him  who  desires  to  do  his  full  duty  to  his  patient  and 
himself. 


PHYSICAL    SIGNS. 


705 


Abnormal    thickness    or    ten- 
sion of  abdominal  walls 


Distention   of  abdominal   vis- 
cera • 


Fluid  accumulation  within  the 
peritoneum 


Cystic  disease  of  other  parts  < 
in  the  abdomen 


Excessive  development  or  dis 
placement   of  other   viscera  < 
of  the  abdomen 


Pregnancy 


Diseased  states  of  pelvic  walls 
and  areolar  tissue 


Obesity ; 

(Edema ; 
I    Elephantiasis ; 
[  Tonic  spasm. 

Tympanites  ; 

Fecal  tumor  ; 

Dilatation  of  stomach  ;' 

Distended  bladder ; 

Ilematometra ; 

Physometra ; 

Cystic  chorion  ; 
.  Hydrosalpinx, 
f  Ascites ; 

J   Encysted  dropsy ; 
■    Hematocele  ; 
[  Colloid  accumulation. 

Cyst  of  broad  ligament ; 

Renal  cyst ; 

Splenic  cyst ; 

Hepatic  cyst ; 

Parasitic  cyst ; 

Subperitoneal  cyst ; 

Uterine  cyst ; 

Uterine  cysto-fibroma. 

Uterine  fibroma  ; 

Pmlarged  spleen  ; 

Enlarged  liver ; 

Fibro-plastic  tumor  of  peritoneum  ; 

Sarcoma  of  abdominal  glands  ; 

Malignant  disease ; 

Omental  tumor ; 

Displaced  kidney ; 

Displaced  liver. 

Normal ; 

(  Ventral ; 

Extra-uterine  <  Tubal ; 

(interstitial ; 

"With  amniotic  dropsy  ; 

With  ovarian  dropsy  ; 

With  dead  child. 
f  Enchondroma  ; 
J   Encephaloid  of  bones  ; 
[  Pelvic  abscess. 


1  A  most  remarkable  and  interesting  instance  of  this  is  recorded  by  Dr.  Reeves 
Jackson,  of  Chicago. 
45 


706  OVARIAN    CYSTS. 

Abnormal  Thickness  or  Tension  of  Abdominal  Walls Obesity  will  be 

recognized  by  obscure  resonance  on  percussion  over  tbe  whole  abdomen ; 
by  absence  of  a  defined,  resisting  outline  to  the  supposed  tumor ;  by  the 
possibility  of  catching  the  fatty  walls  between  the  two  hands,  lifting  them, 
and  rolling  them  over  the  muscular  floor  beneath ;  by  the  deep  depression 
which  can  be  made  when  the  patient  is  anaesthetized  ;  and  by  the  pendu- 
lous folds  created  by  assumption  of  the  sitting  posture.  It  would  be 
inexcusable  in  an  expert  to  mistake  this  condition  for  ovarian  tumor,  but 
for  an  inexperienced  examiner  not  at  all  ho.  I  see  numerous  cases  every 
year  in  which  such  an  error  is  committed  by  very  competent  practitioners. 

CEdema  will  be  known  by  pitting  upon  pressure ;  by  the  existence  of 
the  same  condition  in  the  areolar  tissue  of  the  feet  or  face ;  and  by  its 
generally  attending  uraemia,  chlorosis,  or  cardiac  disease. 

Elephantiasis,  of  which  Dr.  Atlee  records  a  remarkable  case,  would  be 
recognized  by  the  peculiar  structural  alterations  of  the  skin  which  charac- 
terize it. 

Tonic  spasm  of  the  abdominal  muscles  has  more  than  once  led,  as  has 
indeed  obesity,  to  abdominal  section  for  removal  of  a  tumor.  It  often  oc- 
curs under  the  name  of  "  phantom  tumor"  in  very  hysterical  women,  and 
is  not  rare  as  a  reflex  result  of  caries  of  the  vertebrae.  It  may  be  diagnos- 
ticated by  resonance  on  percussion  ;  absence  of  fluctuation  ;  and  absence 
of  all  signs  of  tumor  under  anaesthesia.  In  case  of  doubt,  anaesthesia 
should  always  be  resorted  to.  In  addition  to  these  signs,  the  unaltered 
position  of  the  uterus  constitutes  an  important  one. 

Distention  of  Abdominal  Viscera — Even  without  abdominal  spasm  a 
large  amount  of  air  sometimes  accumulates  in  the  intestines  from  hysteria, 
digestive  disorder,  or  great  obstruction  in  the  canal.  It  may  be  known 
by  resonance  on  percussion  ;  absence  of  fluctuation  ;  absence  of  all  signs 
of  tumor  upon  examination  under  anaesthesia  ;  and  the  normal  position 
of  the  uterus.  By  firm,  steady  pressure  downwards  towards  the  spine, 
kept  up  and  increased  after  each  expiration,  resistance  will  be  overcome, 
and  deep  exploration  prove  the  absence  of  a  tumor.  This  method  was 
systematized  by  Roederer. 

Fecal  tumor  will  be  marked  by  absence  of  fluctuation;  a  peculiar 
"doughy"  sensation  upon  manipulation;  pain  upon  pressure;  constipa- 
tion ;  violent  colic  ;  and,  most  valuable  sign  of  all,  the  creation  of  a  dis- 
tinct pit  or  depression  when  steady  pressure  is  made  at  one  point,  the 
patient  being  anaesthetized.  The  action  of  cathartics  and  enemata  is  often 
entirely  delusive  as  a  test  of  fecal  tumor. 

Dr.  Atlee  relates  a  case  of  distention  of  the  stomach  in  a  man,  in  which 
that  organ  filled  the  entire  abdominal  cavity,  and  covered,  like  an  apron, 
all  the  other  abdominal  organs.  "  Had  the  patient  been  a  female,"  says 
he,  "  I  should  at  once  have  pronounced  it  an  ovarian  cyst."  Explorative 
incision  would  alone  have  accomplished  diagnosis. 


FLUID    PERITONEAL    ACCUMULATIONS.  707 

It  may  be  thought  unlikely  that  a  distended  bladder  could  be  mistaken 
for  an  ovarian  cyst,  but  it  often  gives  the  appearance  of  one.  In  one  ease 
in  which  this  difficulty  had  existed  for  three  weeks,  I  found  the  bladder 
distended  so  as  to  reach  above  the  umbilicus,  its  neck  being  compressed 
by  the  neck  of  a  retroverted  pregnant  uterus.  Suspicion  as  to  the  nature 
of  the  tumor  will  be  excited  by  interference  with  urination,  constant  in- 
voluntary discharge  of  urine  taking  place,  and  the  very  frequent  concur- 
rence, according  to  my  experience,  of  retroversion  of  the  pregnant  uterus. 
Should  aspiration  be  practised,  the  physical  and  chemical  features  of  the 
urine  will  suggest  a  resort  to  the  catheter,  which  will  settle  the  question 
of  diagnosis. 

In  considering  the  differentiation  of  hematometra,  physometra,  and 
cystic  degeneration  of  the  chorion,  little  reliance  should  be  placed  upon 
rational  signs  in  comparison  with  physical.  Cessation  of  menstruation 
and  many  of  the  other  signs  of  pregnancy  will  be  discovered  in  most  cases, 
and,  in  physometra  and  cystic  chorion,  characteristic  discharges  will  usu- 
ally attend — air  in  the  former,  and  bloody  serum  in  the  latter.  The  en- 
larged uterus  will  be  recognized  as  the  tumor  in  question  by  conjoined 
manipulation  and  Simon's  method;  but  the  decisive  test  of  these  condi- 
tions consists  in  the  passage  of  the  uterine  sound,  or  of  a  silver  catheter  to 
the  fundus,  in  order  to  allow  of  escape  of  imprisoned  material,  which, 
being  collected,  may  be  submitted  to  chemical  and  microscopical  exami- 
nation. 

Hydrosalpinx  sometimes  develops  into  a  large  tumor.  De  Haen  de- 
scribes one  which  weighed  seven  pounds.  To  differentiate  such  a  con- 
dition from  ovarian  cyst,  but  two  methods  can  be  relied  upon  :  first,  the 
removal  of  fluid,  and  examination  by  chemical  means  and  the  microscope; 
and  second,  explorative  incision. 

Fluid  Peritoneal  Accumulations It  is  often   exceedingly  difficult  to 

differentiate  between  ascites  and  ovarian  dropsy.  The  means  which  ordi- 
narily enable  us  to  do  so  are  here  stated.  It  must,  however,  be  borne  in 
mind  that  there  are  cases  in  which  even  the  most  important  may  be  trans- 
posed. For  example,  an  ovarian  cyst  sometimes  establishes  communica- 
tion with  the  intestines,  and  becomes  resonant ;  while,  in  ascites,  where 
the  amount  of  fluid  is  excessive  and  the  mesentery  short,  dulness  exists 
over  the  front  of  the  abdomen.  The  rule  is  here  adhered  to,  but  the  ex- 
ceptions must  not  be  lost  sight  of. 

In  Ovarian  Dropsy.  In  Ascites. 

1st.  A  small,  round  tumor  will  often  |      1st.  The  enlargement  will  have  shown 
have  shown  itself  in  the  beginning  in     no  small  tumor  at  any  point ; 
one  iliac  fossa ; 

2d.  In  supine  posture  a  rotundity  is  |  2d.  In  supine  posture  the  fluid  gravi- 
observed  in  the  abdomen  ;  :  tates  to  sides  of  abdomen,  and  the  ab- 

I  dominal  surface  is  flattened  ; 


708 


OVARIAN    CYSTS. 


Is  Ovarian  Dropsy. 
3d.  Percussion  made  in  supine  posture 
gives  dulness  over  surface  of  abdomen  ; 

4th.  Change  of  posture  alters  area  of 
dulness  but  little ; 

5th.  No  evidences  of  cardiac,  renal,  or 
hepatic  disease  exist  as  a  rule  ; 

oth.  Skin  is  normal  as  to  color,  mois- 
ture, etc. ; 

7th.  CEdemaof  the  feet  is  absent  until 
a  late  period,  when  the  patient  has  be- 
come exhausted  ; 

8th.  Health  fails  slowly  ; 

9th.  Sitting  posture  affects  shape  of 
abdomen  but  little  ; 

10th.  Fluctuation  ordinarily  not  so 
superficial,  level  fixed  to  great  extent, 
ceases  where  intestinal  resonance  begins; 

11th.  Aortic  pulsation  transmitted  ; 

12th.  Fluid  usually  amber  colored  and 
tenacious,  often  like  syrup,  of  various 
hues  in  polycysts,  not  spontaneously  co- 
agulable,  always  sticky  when  rubbed 
between  fingers.  Shows  cylindrical  epi- 
thelium, granular  cells  and  matter,  oil 
globules,  and  cholesterine,  and  contains 
paralbumen  and  metalbumen.  The  gra- 
nular cell  is  distinguishable  from  other 
cells  by  its  merely  becoming  transpa- 
rent by  acetic  acid  ;  others  increase  in 
size  ;' 

Specific  gravity,  1.018  to  1.024. 


Ix  Ascites. 

3d.  Percussion  gives  resonance  over 
abdominal  surface  because  the  intestines 
float  on  the  fluid  ; 

4th.  Change  of  posture  alters  area  of 
dulness  markedly  ; 

5th.  Evidences  of  cardiac,  renal,  or 
hepatic  disease  almost  always  exist ; 

6th.  Skin,  in  majority  of  cases,  gives 
evidences  of  cirrhosis  by  its  parchment 
feel  and  jaundiced  hue  ; 

7th.  (Edema  of  the  feet  exists  as  an 
early  sign ; 

8th.  Health  fails  early  and  rapidly ; 

9th.  Produces  bulging  often  in  Doug- 
las's pouch  and  through  navel ; 

10th.  More  superficial,  level  changes 
with  change  of  posture,  perceived  even 
where  intestinal  resonance  exists. 

11th.  Not  so. 

12th.  Fluid  of  light  straw-color  ;  spon- 
taneously coagulable  from  containing 
fibrin  ;  without  sediment  usually;  shows 
to  microscope  squamous  epithelial  cells, 
oil  globules,  pus  cells,  and  amoeboid 
bodies ;  does  not  contain  paralbumen, 
metalbumen,  or  cholesterine ; 


Specific  gravity,  1.010  to  1.015. 


Sometimes,  however,  peritoneal  accumulations  are  sacculated  by  en- 
compassing lymph  in  one  portion  of  the  peritoneum  ;  among  the  intestines 
matted  together  by  effused  lymph  ;  or,  as  in  a  case  recorded  by  "West, 
enveloped  by  the  omentum.  "  Between  four  and  five  quarts,"  says  he, 
"  of  a  dark  fluid  were  found  collected  between  the  folds  of  the  peritoneum." 
The  amount  of  fluid  thus  imprisoned  is  often  very  large,  and  hence  the 
difficulties  of  diagnosis  which  have  led  Mr.  Wells2  to  assert,  "  I  am  aware 
of  no  means  by  which  such  cases  are  to  be  distinguished  from  ovarian 
dropsy."  McDowell  himself  once  opened  an  abdomen  in  such  a  case  under 
the  belief  that  an  ovarian  tumor  existed.  The  intestines  do  not  rise  above 
the  fluid  as  in  simple  ascites,  but  there  is  less  rotundity  to  the  mass,  and 
less  interference  with  respiration  than  are  found  to  exist  with  ovarian  cyst. 


1  Drvsdale. 


2  Dis.  of  Ovaries,  p.  134. 


CYSTIC    DISEASE    OF    OTHER    PARTS    IN    ABDOMEN.         709 

Diagnosis  in  these  difficult  cases  must  depend  upon  the  results  of  aspira- 
tion, examination  of  contained  fluids,  Simon's  method,  and  explorative 
incision. 

The  sudden  appearance  of  hematocele,  the  immediate;  and  often  urgent 
symptoms  which  it  excites,  and  the  removal  of  a  little  fluid  by  aspiration 
will  settle  the  question  of  diagnosis. 

Colloid  disease  sometimes  affects  the  whole  peritoneal  cavity.  In  some 
cast's  it  appears  to  escape  into  it  from  a  ruptured  ovarian  cyst;  in  others 
it  originates  there.  Removal  of  a  small  amount  of  the  characteristic 
material  by  tapping  is  the  only  means  of  diagnosis. 

Cystic  Disease  of  other  Parts  in  the  Abdomen Cysts  of  the  broad 

ligament  so  closely  resemble  unilocular  ovarian  cysts  as  to  be  diagnostic- 
able  only  by  explorative  incision  or  aspiration.  Their  character  might 
be  suspected  from  superficiality  of  fluctuation,  slight  implication  of  general 
health,  absence  of  emaciation,  and  slowness  of  growth ;  but  the  chemical 
and  microscopical  features  of  the  contained  fluid  would  alone  decide  posi- 
tively. This  fluid  is  as  clear  and  pure  in  appearance  as  distilled  water, 
showing  when  boiled  after  addition  of  acetic  acid  only  a  trace  of  albumen 
as  an  albuminate  ;  is  loaded  with  chloride  of  sodium  ;  and  contains  only  a 
few  fat  and  blood  globules.  After  evacuation  the  cyst  walls  cannot  be 
felt,  and  tapping  often  proves  curative.  Spiegelberg  removed  such  a 
cyst  in  18G9,  the  walls  of  which,  unlike  those  of  ovarian  tumors,  contained 
muscular  fibres,  and  the  fluid  of  which  contained  albumen. 

Renal  cysts  have  several  times  deceived  the  most  skilful  diagnosticians. 
Their  characteristics  are  these  :  they  ordinarily  push  the  intestines  for, 
wards  and  not  backwards  ;  pus,  blood,  and  albumen  usually  occur  in  the 
urine  ;  these  tumors  grow  from  above  downwards  ;  they  are  rare  and  grow 
slowly ;  may  be  pushed  up  so  that  resonance  occurs  between  tumor  and 
pelvis  ;  and  the  fluid  contained  shows  none  of  the  microscopical  features 
of  ovarian  cyst,  while  it  shows  the  chemical  and  microscopical  elements 
of  urine.  Sometimes  echinococci,  which  are  frequent  in  renal  cysts  and 
unknown  in  ovarian,  are  found.  The  tumor  is  apt  to  be  crossed  by  the 
descending  colon  or  to  lie  outside  of  the  ascending  colon  ;  it  is  usually 
marked  by  renal  and  not  by  menstrual  derangement ;  and  is  usually  uni- 
lateral. 

Sometimes,  however,  a  renal  cyst  occupies  a  median  position  ;  extends 
like  an  ovarian  tumor  into  the  pelvis  ;  is  attached  to  the  pelvic  organs ; 
pushes  the  intestines  aside  like  an  ovarian  cyst ;  contains  fluid  free  from 
elements  of  urine  ;  and  even  presents  cholesterine  and  paralbumen.  In 
such  cases  the  determination  of  the  point  of  attachment  by  Simon's  method 
constitutes  a  most  valuable  resource. 

Splenic  and  hepatic  cysts  are  rare,  grow  from  above  downwards,  give 
an  area  of  dulness  between  tumor  and  pelvis,  and  in  the  fluid  of  the  latter 


710  OVARIAN    CYSTS. 

the  echinococcus  is  often  discovered.  In  both  Simon's  method  is  of  great 
value  as  a  means  of  differentiation. 

Parasitic  cysts,  the  result  of  the  presence  of  the  echinococcus,  may 
develop  in  any  of  the  organs  or  tissues  of  the  abdomen.  Should  the  posi- 
tion of  the  tumor  be  such  as  to  lead  to  doubt  as  to  differentiation  between 
it  and  ovarian  cyst,  diagnosis  would  be  attainable  only  by  aspiration  and 
examination  by  the  microscope  and  chemical  means.  The  former  would 
show  the  presence  of  the  parasite. 

Subperitoneal  cysts  are  distinguishable  from  ovarian  only  by  physical 
features  of  contained  fluid  and  explorative  incision. 

Cysts  growing  from  the  uterus  itself  are  not  common.  They  may  be 
recognized  by  Simon's  method,  by  the  chemical  examination  of  their 
contents,  and  by  the  curative  effects  of  tapping.  Atlee  reports  three  cases 
thus  cured.  Furthermore,  the  fluid  which  they  contain  separates  into  a 
coagulum  and  a  pinkish  or  bright  red  portion  which  does  not  coagulate, 
and  the  peculiar  cells  of  ovarian  fluid  do  not  appear  in  it.  Ovarian  fluid 
never  spontaneously  coagulates. 

Fibro-cystic  tumors  are  difficult  of  differentiation  from  ovarian  cystomata, 
but  when  we  compare  our  present  position  with  reference  to  this  subject 
with  what  it  was  only  a  few  years  ago  we  have  great  cause  for  congratula- 
tion. I  here  give  only  the  most  prominent  differences  between  the  two 
diseases,  and  hence  those  upon  which  reliance  can  really  be  placed.  To 
many  of  these  even,  however,  there  are  exceptions ;  to  several  there  are 
none. 

Uterine  Fibro-cyst.                    ,  Ovarian  Cyst. 

Gruws  slowly  and  occurs  usually  after  Grows  more  rapidly  and  is  less  gov- 

thirty  years  of  age.                                      j  erned  by  age. 

Uterine  cavity  generally  enlarged.  Uterine  cavity  not  usually  enlarged. 

Connection  of  tumor  and  uterus  usu-  j  Uterus  more  independent  of  tumor. 
ally,  though  not  always,  intimate. 

Fluid  spontaneously  and  quickly  co-  Never  does  so. 
agulates. 

Uterus  sometimes  lifted  above  pubes  Uterus  generally  behind  tumor, 
and  out  of  pelvis,  often  in  front  of  tumor. 

Health  remains  good  for  years.  Generally  fails  within  three  years. 

Microscope  shows  fibre  cell  (Drysdale).  Shows  the  peculiar  granular  and  epi- 
thelial cells  of  ovarian  cyst. 

Although  these  signs  are  all  of  some  value,  those  which  should  be  re- 
garded as  most  reliable  are  the  following:  spontaneous  coagulability  of 
contained  fluid  ;  presence  of  the  fibre  cell  ;  increased  capacity  of  the 
uterus  ;  and  the  determination  of  its  connection  with  the  tumor  by  means 
of  Simon's  method  of  rectal  exploration.  Explorative  incision  should  not 
rank  high  as  a  diagnostic  method,  for  simple  section  of  the  abdominal 
walls  is  not  enough,  and  the  exploration  which  is  further  required  to 
decide  the  point  exposes  the  patient  to  great  danger. 


NORMAL  AND  ABNORMAL  PREGNANCY.         711 

Excessive  Development  or  Displacement  of  other  Viscera If  ascites  do 

not  attend  hepatic  and  splenic  enlargement,  there  will  never  be  any  great 
difficulty  in  distinguishing  them  from  ovarian  cystoma.  Should  it  do  so, 
tapping  should  be  resorted  to. 

Uterine  fibroma  may  be  recognized  by  its  peculiar  hardness,  slowness 
of  growth,  absence  of  fluctuation,  continuance  of  good  health  and  absence 
of  emaciation,  tendency  to  increased  menstrual  flow,  irregular  surface, 
intimate  connection  with  uterus,  increase  in  capacity  of  this  organ,  and 
absence  of  fluid  upon  aspiration  or  tapping.  It  must  not  be  forgotten, 
however,  that  the  uterus  may  be  normal  in  size,  and  the  tumor  entirely 
independent  of  it. 

"  The  symptoms  caused  by  the  growth  of  large,  fatty,  and  fibro-plastic 
tumors  from  various  parts  of  the  peritoneum  or  mesentery,"  says  Spencer 
"Wells,1  "so  much  resemble  those  of  true  ovarian  disease,  that  their  real 
nature  can  only  be  determined  in  some  cases  by  an  exploratory  incision 
or  tapping."  Should  fluid  be  removed  from  them  it  would  lack  the  pecu- 
liar ovarian  cellular  elements,  and  would  spontaneously  coagulate,  and 
Simon's  method  would  in  some  cases  demonstrate  the  fact  that  the  point 
of  origin  is  not  the  ovary. 

A  movable  or  floating  kidney  might  be  mistaken  for  an  ovarian  cyst, 
but  for  so  small  a  one  that  the  question  of  ovariotomy  would  not  arise  in 
connection  with  it.  Time  would  prove  that  it  was  not  a  growing  ovarian 
cyst. 

Dr.  J.  K.  Dale,2  of  Little  Rock,  Arkansas,  reports  an  interesting  case 
of  tumor  supposed  to  be  ovarian,  but  which  upon  explorative  incision  was 
found  to  be  the  liver,  which  was  "free  and  movable,  very  much  enlarged, 
occupying  the  right  half  of  the  pelvis,  encroaching  upon  the  bladder  and 
rectum,  and  interfering  very  materially  with  the  due  performance  of  their 
respective  functions."  I  had  myself  precisely  the  same  experience  in  a 
case  in  which  I  made  an  explorative  incision  in  New  Haven,  in  presence 
of  Drs.  Whittemore,  Jewett,  and  others. 

Pregnancy — The  ordinary  signs  of  utero-gestation,  both  rational  and 
physical,  should  be  carefully  considered  in  eliminating  normal  and  inter- 
stitial pregnancy.  More  than  one  woman  has  died  from  the  passage  of  a 
trocar  and  canula  into  the  pregnant  uterus  after  abdominal  incision,  an 
accident  certainly  scarcely  more  deplorable  for  the  patient  than  for  the 
unfortunate  practitioner  whose  carelessness  causes  it.  I  say  carelessness, 
for  the  reason  that  the  passage  of  the  uterine  sound  as  a  means  of  differen- 
tiation would  always  prevent  error.  True,  this  would  result  in  premature 
labor  in  normal  pregnancy,  but  how  much  better  this,  even  at  the  sacri- 
fice of  the  child's  life,  than  the  terrible  mishap  just  alluded  to. 

During  the  past  eighteen  months  three  cases  of  pregnancy  at  full  term 

1  Op.  cit,,  p,  140.  2  Richmond  and  Louisville  Med.  Journ.,  April,  1874. 


712  OVARIAN    CYSTS. 

have  been  referred  to  me  as  ovarian  cysts,  and  this  not  by  ignorant  men 
but  by  very  capable  practitioners.  Two  out  of  the  three  pregnancies  were 
illegitimate,  and  the  examiners  were  misled  by  relying  upon  rational  in- 
stead of  physical  signs.  Reliance  should  be  placed  especially  upon  dis- 
covery of  the  foetal  body  and  movements  by  careful  palpation ;  upon  bal- 
lottement  between  the  fifth  and  seventh  months  ;  upon  recognition,  by 
vaginal  touch,  of  the  movable  presenting  part  after  that  time ;  and  upon 
the  foetal  heart  sounds  and  placental  bruit.  The  gastric,  mammary,  and 
nervous  symptoms  of  pregnancy  sometimes  result  from  ovarian  disease. 

Should  the  child  be  dead  many  of  these  symptoms  will  be  absent,  and  if 
it  be  retained  in  utero,  as  it  sometimes  is,  for  many  years,  diagnosis  must 
depend  upon  the  history  of  the  case,  Simon's  method,  the  uterine  sound, 
and  dilatation  of  the  cervix  so  as  to  admit  of  digital  exploration.  In  tubal 
or  ventral  pregnancy  diagnosis  would  prove  more  difficult,  but  the  same 
means  will  aid  in  making  it,  for  even  when  the  foetus  is  developed  out  of 
the  uterus  that  organ  enlarges  decidedly. 

Not  only  should  a  differential  diagnosis  be  made  between  pregnancy 
and  ovarian  tumor  ;  even  after  recognition  of  the  latter,  the  former  should 
always  be  eliminated  as  a  coincident  condition. 

Dropsy  of  the  amnion  gives  very  superficial  fluctuation,  and  might  de- 
ceive one  not  careful  in  diagnosis.  A  patient  investigation  of  the  case, 
and  consideration  of  its  history  would  ordinarily  remove  all  doubt.  The 
fibres  of  the  cervix  uteri  are  usually  expanded,  the  cervix  moves  as  the 
tumor  is  rolled  in  the  abdomen,  and  the  uterine  sound  passes  far  up  into 
the  cavity  above.  Should  aspiration  have  been  resorted  to,  the  fluid  re- 
moved will  be  found  to  present  the  following  features.  It  is  alkaline,  with 
specific  gravity  1005  to  1010,  contains  albumen  but  no  fibrin,  and  presents 
to  the  microscope  epithelial  cells  and  oil  globules.  Meconium  and  blood 
alter  these  features. 

Diseased  States  of  Pelvic  Walls  and  Areolar  Tissue Enchondroma 

or  encephaloid  disease  of  the  pelvic  walls  is  hard,  free  from  fluctuation, 
and  firmly  fixed  and  united  to  the  part  from  which  it  grows.  Rectal 
exploration  and  abdominal  palpation  will  prove  these  facts,  and  if  aspira- 
tion be  attempted  the  absence  of  fluid  will  be  evidenced. 

Pelvic  abscess  usually  results  from  cellulitis,  which  presents  marked 
symptoms.  It  rarely  extends  to  the  umbilicus,  hardness  will  be  felt  in 
one  or  other  iliac  fossa,  it  is  fixed  in  the  pelvis,  and  aspiration  gives  evi- 
dence of  pus.  Excessive  pain  attends  it,  with  throbbing  and  pain  down 
one  thigh,  and  the  outline  of  the  mass  is  obscure  and  unsatisfactory.  There 
is  often  a  tendency  to  point,  there  is  pain  upon  pressure,  and  there  are 
generally  chills  and  fever. 

In  the  early  days  of  ovariotomy,  when  adhesions  were  regarded  as  a 
bar  to  extirpation  of  these  tumors,  the  question  of  the  existence  of  adhe- 
sions possessed  important  bearings.    Now,  however,  when  even  the  firmest 


FLUID    TUMORS.  713 

attachments  are  broken  not  only  with  impunity,  but  with  results  which 
arc  often  better  than  those  which  follow  the  removal  of  a  tumor  from  a 
healthy  peritoneum,  it  sinks  into  comparative  insignificance.  This  is  a 
most  fortunate  fact,  for  the  reason  that  the  determination  of  the  existence 
of  adhesions  is  little  more  than  guess-work.  Beyond  a  few  very  general 
facts  by  which  we  may  venture  to  form  a  surmise,  all  is  empirical  predic- 
tion with  reference  to  the  matter. 

If  the  case  have  developed  very  rapidly  and  be  believed  to  be  unilocular, 
there  are  probably  no  adhesions. 

If  there  have  been  symptoms  of  peritonitis,  there  are  probably  adhe- 
sions.    If  the  case  have  been  painless,  there  are  probably  none. 

Should  the  abdominal  walls  roll  freely  over  the  tumor,  the  patient  lying 
upon  her  back,  and  should  the  tumor  fall  low  in  the  abdomen  as  she  sud- 
denly sits  up,  there  are  probably  no  anterior  adhesions.  But  posterior 
ones  may  exist,  and  not  be  suspected  from  this  examination. 

If,  upon  vaginal  examination,  the  uterus  and  base  of  the  tumor  exhibit 
immobility  such  as  is  found  in  pelvic  peritonitis,  and  if,  upon  change  of 
posture  from  erect  to  supine,  these  parts  do  not  retreat  from  the  finger  in 
the  vagina,  there  are  in  all  probability  strong  pelvic  adhesions. 

All  these  signs  are  unreliable,  and  disappointment  will  surely  follow 
any  great  degree  of  confidence  which  is  reposed  in  them,  but  a  compensa- 
tion is  to  be  found  in  the  fact  already  stated  that  even  firm  adhesions  do 
not  contraindicate  removal. 

It  is  always  desirable  to  know  the  length  of  the  pedicle.  This  point 
can  be  approximatively  settled,  in  a  certain  number  of  cases,  by  the  means 
recommended  by  Tixier,1  of  Strasbourg.     He  says  : — 

"Practice  and  observation  have  enabled  us  to  diagnose,  in  certain  cases, 
the  probable  length  and  variety  of  the  pedicle.  Certain  objective  and  sub- 
jective signs  ma3r  guide  the  practitioner  and  facilitate  bis  diagnosis  ;  a  very 
important  matter,  since  on  the  length  of  the  pedicle  often  depends  the 
success  of  the  operation. 

"We  have  hitherto  been  able  to  diagnose  with  almost  perfect  certainty 
three  varieties :  the  long,  short,  and  twisted  pedicle. 

uThe  long  pedicle— The  form  of  the  abdomen  has  a  peculiar  aspect ;  this 
is  the  form  en  besace.  The  hypogastric  portion  of  the  abdominal  wall  is 
applied  to  the  internal  surfaces  of  the  thighs,  and  the  ovarian  tumor, 
forcibly  projected  forwards,  seems  to  be  removed  from  the  superior  entrance 
of  the  pelvis.  A  vaginal  examination  reveals  an  elevation  of  the  cervix 
uteri,  and  the  index  finger  passed  into  the  pelvic  excavation  does  not  meet 
with  the  tumor  at  any  point.  The  womb  is  very  movable  and  can  be 
readily  displaced.  The  collection  of  these  symptoms  induces  one  to  pre- 
sume that  there  is  an  elongated  condition  of  the  broad  ligament  and  of  the 

1  Le  Pedicule  et  son  Traitement  apres  l'-Operation  de  l'Ovariotomie,  Strasbourg, 
1SG9  ;  Archives  Centrales  de  Medecine,  Juillet,  1870. 


714  OVARIAN    CYSTS. 

Fallopian  tube,  a  condition  favorable  for  forcing  the  pedicle  without  the 
abdominal  wound. 

"The  short  pedicle. — The  existence  of  the  short  pedicle  may  be  assumed 
in  the  presence  of  the  following  symptoms  :  in  the  first  place,  the  form  of 
the  abdomen  differs  from  that  described  above  ;  one  may  observe  a  lateral 
extension  without  pronounced  prominence  of  the  median  portion.  In  at- 
tempting to  introduce  the  tip  of  the  finger  between  the  tumor  and  the 
pubes,  one  feels  through  the  skin  that  the  growth  passes  into  the  pelvic 
excavation  ;  its  base  seems  to  be  seated  over  the  pelvic  opening.  The 
vaginal  touch  denotes  a  sinking  of  the  cervix  uteri,  and  a  more  or  less  pro- 
nounced immobility  of  the  womb.  If  the  pelvic  excavation  be  then  ex- 
plored with  the  finger,  one  feels  that  it  is  not  free,  and  that  certain  parts 
of  the  tumor  are  contained  within  it.  In  the  presence  of  these  facts  the 
surgeon  may  assume  that  there  is  a  greater  or  less  degree  of  shortening  of 
the  pedicle. 

''The  ticisted  jjediclc. — At  first  sight  this  torsion  seems  difficult  to  deter- 
mine. It  may,  however,  under  certain  conditions,  be  diagnosed  with  greater 
certainty  than  the  two  preceding  varieties.  Its  existence  maybe  concluded 
whenever  the  following  symptoms  have  been  observed  : — 

;tThe  patients  experience  at  intervals  very  acute  pains  radiating  down- 
wards along  the  vein  corresponding  to  the  affected  ovary,  and  upwards  to 
the  lumbar  region  on  the  same  side.  These  pains  are  excited  by  work  and 
fatigue.  They  break  out  also  when  the  patient  is  in  bed,  and  when  she 
wishes  to  change  her  position.  One  hears  also  from  these  patients  of  very 
strong  uterine  cramps  analogous  to  those  occasioned  by  deligation  of  the 
pedicle.  The  cystic  fluid  is  more  or  less  deep  in  color,  presenting  a  hemor- 
rhagic appearance.  The  touch  in  these  cases  gives  no  precise  indication. 
One  can  only  acquire  the  idea  of  the  existence  of  an  habitually  long  and 
thin  pedicle  in  cases  of  this  kind." 

Although  I  have  not  been  able  to  draw  as  positive  and  certain  conclu- 
sions in  reference  to  the  determination  of  the  length  and  character  of  the 
pedicle,  by  aid  of  these  means,  as  M.  Tixier  has,  I  nevertheless  regard  his 
suggestions  as  valuable,  and  well  worthy  of  application  to  every  case  in 
which  ovariotomy  is  contemplated.  One  rule  which  I  have  found  very 
reliable  is  this — if  the  tumor  be  found  far  up,  out  of  the  pelvis,  upon  vagi- 
nal examination,  the  pedicle  cannot  be  very  short.  If  a  tumor  which  is 
not  very  large  be  fixed  in  the  pelvis  so  that  it  cannot  be  pushed  out,  the 
pedicle  is  probably  a  short  one.  The  value  of  this  sign  may  be  increased 
by  examining  in  the  knee-elbow  position. 

When  doubts  exist  upon  any  of  the  points  here  stated,  which  cannot  be 
removed  by  those  means  of  investigation  which  are  limited  by  the  abdo- 
minal walls  and  pelvic  roof;  which,  in  other  words,  extend  to,  but  not 
beyond,  the  peritoneum  in  their  immediate  application,  there  exist  three 
methods  of  exploration  which  bring  the  explorer  into  direct  contact  with 
the  interior  of  the  abdomen  and  of  the  tumor.     Those  positive  and  reliable 


FLUID    TUMORS.  715 

means,  which  may  justly  be  styled  the  crucial  tests  of  abdominal  tumors, 
are  the  following: — 

Aspiration  ; 
Tapping; 

Explorative  incision. 
To  these  a  certain  amount  of  danger  undoubtedly  attaches ;  but  when 
compared  with  the  great  danger  arising  from  operation  upon  an  uncertain 
diagnosis,  it  becomes  trivial.  Many  an  inappropriate  case  has  been  sub- 
mitted to  the  operation  of  ovariotomy  which  would  have  been  spared  it, 
with  the  promise  of  a  prolongation  of  life,  had  one  of  these  methods  been 
previously  employed.  They  are  of  course  not  to  be  confined  to  the  deter- 
mination of  the  character  of  a  tumor  alone,  but  that  of  the  origin,  attach- 
ments, and  complications  of  any  abdominal  growth. 

Aspiration The  introduction  of  aspiration   into  use  for  the  diagnosis 

of  ovarian  tumors  constitutes  a  decided  advance.  The  instrument  gene- 
rally employed  in  this  country  is  that  of  Dieulafoy,  shown  in  Fig.  28.  By 
tills  a  delicate,  hollow  needle  is  passed  into  the  tumor,  and  powerful  suction 
applied  through  an  India-rubber  tube  connected  with  a  strong  syringe,  in 
which  a  vacuum  is  created  by  an  upward  movement  of  the  piston.  Through 
the  most  delicate  needle  clear  fluids  will  pass,  and  through  the  largest, 
which  is  very  small  when  compared  with  an  ordinary  trocar  and  canula, 
very  tenacious  colloid  material  may  be  drawn.  By  this  beautiful  instru- 
ment a  large  polycystic  tumor  filled  with  tenacious,  syrupy  fluid  may  be 
readily  emptied  by  turning  the  needle  into  new  cysts  as  those  first  punc- 
tured are  evacuated.  And  when  complete  evacuation  is  not  desired,  it 
furnishes  a  supply  of  fluid  for  chemical  and  microscopical  examination.  It 
greatly  diminishes  the  dangers  of  such  evacuation  as  compared  with  those 
resulting  from  tapping.  The  dangers  attending  that  operation  are  the  fol- 
lowing :  1st,  hemorrhage  from  a  bloodvessel  in  the  abdominal  or  cyst  wall; 
2d,  admission  of  air  to  the  cavity  of  the  sac  and  decomposition  of  fluid, 
which  may  create  inflammation  of  the  cyst  wall  and  septicaemia;  3d,  sub- 
sequent escape  of  the  contents  of  the  tumor  into  the  peritoneum  ;  and  4th, 
fatal  injury  from  wounding  of  an  intestine  or  solid  organ.  Spencer  "Wells 
mentions  a  case  in  which  an  acquaintance  of  his  tapped  a  patient  who  died 
soon  after.  Upon  autopsy  two  and  a  half  quarts  of  blood,  which  had 
escaped  from  a  wounded  varicose  vein,  were  found  in  the  peritoneal  cavity. 
All  these  dangers  are  considerable  from  ordinary  tapping  ;  decidedly  less 
so  from  aspiration. 

It  may  then  safely  be  said  that  aspiration  accomplishes  all  that  tapping 
does,  at  infinitely  less  risk,  and  that  the  former  should,  when  practicable, 
always  be  preferred  to  the  latter  procedure.  Unfortunately  the  cost  of  the 
aspirator  is  large,  and  it  may  not  be  attainable,  or  the  fluid  may  be  too 
thick  to  flow  through  it.  When  it  is  desired  merely  to  obtain  a  small 
amount  of  fluid  for  examination,  the  hypodermic  syringe  may  be  employed, 


716  OVARIAN    CYSTS. 

even  in  preference  to  the  aspirator.  The  use  of  this  instrument,  which 
was  suggested  hy  Dr.  H.  F.  Walker  and  practised  hy  mycelf  before  our 
knowledge  of  that  just  described,  consists  simply  in  plunging  the  needle 
with  syringe  attached  through  the  abdominal  walls  at  different  points, 
drawing  out  as  much  fluid  as  possible,  and  expelling  this  into  a  test-tube 
for  examination.  This  method  serves  to  determine  the  following  points  : 
1st,  whether  a  tumor  is  fluid  or  solid;  2d,  whether  it  contains  clear, 
slightly  albuminous  fluid  or  ichorous  and  irritating  material ;  3d,  by  means 
of  several  punctures  whether  it  be  multilocular  or  not.  In  1875,  Dr.  Peas- 
lee  declared  that  he  did  not  regard  the  aspirator  as  safer  than  the  trocar. 
Surely  an  instrument  with  which  we  venture  to  tap  the  distended  intes- 
tines, the  pericardium,  and  the  bladder,  must  be  safer  than  one  which  leaves 
so  large  a  hole  as  the  trocar. 

Although  it  has  been  stated  that  aspiration  is  much  less  dangerous  than 
tapping,  it  must  not  be  regarded  as  free  from  danger.  Death  has  repeat- 
edly resulted  from  it,  and  it  should  be  regarded  as  an  axiom  that  all 
abstraction  of  fluid  from  an  ovarian  cyst,  by  whatever  means  it  is  accom- 
plished, is  attended  by  danger.  The  smaller  the  puncture  made,  however, 
the  less  the  danger,  I  think.  Cases  of  peritonitis,  some  of  them  fatal,  after 
aspiration,  are  recorded  by  Atlee,  Little,  Lusk,  Munde,  Gillette,  and 
Jenks ;  cases  of  decomposition  of  sac  contents  and  septic  fever  are  reported 
from  the  same  cause  by  Goodell,  Perujji,  Schnetter,  Skene,  and  myself; 
and  a  case  of  peritonitis  and  adhesions  after  diagnostic  puncture  by  a  hy- 
podermic needle  by  Fauntleroy  of  Virginia. 

Tapping — Tapping  is  a  means  of  great  value  in  the  diagnosis  of  ovarian 
cyst,  and,  where  the  aspirator  is  not  attainable,  should  never  be  lightly 
disregarded.  Atlee,  Wells,  Peaslee,  Spiegelberg,  and  many  other  leading 
ovariotomists  of  our  day  place  great  stress  upon  its  value,  and  although 
some,  like  Stilling,  have  entitled  it,  in  the  warmth  of  deprecation,  "  a 
crime,"  it  may  safely  be  said  to  have  overcome  the  greater  part  of  the 
objections  once  urged  against  it,  and  to  have  fully  established  its  claim  to 
consideration  as  a  valuable  diagnostic  and  palliative  measure.  Wells1  has 
proved  that  it  does  not  considerably  increase  the  mortality  of  ovariotomy. 
It  is  often  even  an  excellent  preparation  for  that  operation,  and,  when 
practised  with  proper  precautions,  its  dangers  are  greatly  diminished.  It 
must  not  be  forgotten,  however,  that  it  is  attended  by  dangers,  which  are 
not  matters  of  speculation,  but  of  fact  established  by  statistical  evidence. 
Of  130  instances  of  first  tappings  analyzed  by  Kiwisch,  17  per  cent,  of 
the  cases  died  within  a  few  hours  or  days  after  the  operation.2  This  is 
certainly  a  mortality  to  be  greatly  dreaded,  especially  when  the  operative 
procedure  which  induces  it  is  not  curative,  but  one  resorted  to  merely  for 
palliation  or  the  accomplishment  of  diagnosis. 

1  Op.  cit.,  p.  275.  2  Hewitt,  op.  cit.,  p.  637. 


tappino.  717 

The  operation  of  paracentesis,  or  tapping,  consists  of  the  introduction 
of  a  trocar  and  canula  through  the  walls  of  a  sac  containing  fluid,  and 
allowing  this  to  flow  away.  Of  all  the  operations  for  relief  of  ovarian 
dropsy  this  is  the  oldest,  and  the  one  which  lias  been  most  frecpuently 
performed.  The  advantages  which  it  offers  are  facility  of  performance, 
quickness  of  relief,  and  immunity,  to  a  certain  extent,  from  the  dangers 
which  attend  more  radical  procedures  adopted  in  these  cases. 

Although,  in  a  limited  number  of  cases,  it  has  been  declared  to  have 
proved  curative,  it  should  never  be  practised  with  any  reliance  upon  its 
doing  so,  for  doubt  exists  as  to  the  authenticity  of  the  facts.  Furthermore, 
it  is  attended  by  the  immediate  dangers  recently  mentioned,  and  by  the 
more  remote  one  of  exhausting  discharge  from  the  sac,  which  may  con- 
tinue so  long  as  to  wear  out  the  patient's  strength.  M.  Courty  collates 
one  hundred  and  thirty  cases  treated  in  this  way  by  Kiwisch,  Lee,  and 
Southam,  of  which  these  are  the  results  : — 

46  died  after  the  1st  tapping. 

10  "         "       2d        " 

26        "         "        3d  to  6th  tapping. 
15        "         "        7th  to  12th    " 
13        "         "        12th  tapping. 

Of  21  of  these  cases  treated  by  Mr.  Southam,  4  died  within  a  few  hours 
after  the  operation,  3  within  the  first  month,  and  14  within  nine  months. 
Kiwisch  lost  9  out  of  64  within  twenty-four  hours  after  the  first  tapping. 
Dr.  Fock,1  of  Berlin,  gives  the  following  table,  displaying  the  dates  at 
which  death  occurred  after  first  operations  in  132  patients : — 

25  died  within  a  few  days. 
24    "         "       6  months. 
22    "         "    .12      " 
21    "         "      24      " 

11  "         "     36      " 

29  only  were  alive  at  end  of  last  date. 

132 

It  will  thus  be  seen  that  reliable  statistical  evidence  places  this  pro- 
cedure in  the  position  of  a  palliative  measure  which  is  generally  followed 
by  advance  of  the  disease,  and  not  rarely  by  immediate  evil  results.  Still 
it  must  not  be  lost  sight  of  that  death  may  be  warded  off  by  the  operation, 
many  existing  evils  alleviated  through  the  course  of  a  period  varying 
from  ten  to  twenty-five  years,  and  that,  in  a  few  cases,  complete  cure  may 
have  been  effected.  Dr.  Ramsbotham  records  an  instance  in  which  one 
hundred  and  twenty-nine  tappings  were  performed  in  eight  years,  and 
four  hundred  and  sixty-one  gallons  of  fluid  removed  ;  and  Dr.  Martineau 
another,  in  which  eighty  operations  evacuated  in  twentyrfive  years  seven 

'  Simpson,  op.  cit.,  p.  347. 


718  OVARIAN    CYSTS. 

hundred  and  twenty-nine  gallons.  I  had  recently  under  my  care  a  patient 
who  for  five  years  has  had  a  large  cyst  which  has  been  tapped  forty-five 
times. 

I  have  stated  that  a  considerable  number  of  cases  are  on  record  in  which 
it  is  asserted  that  simple  tapping  has  cured  ovarian  cystoma.  It  is  a 
matter  of  great  doubt  whether  the  cases  thus  cured  were  true  ovarian 
cysts,  or  cysts  of  the  broad  ligament,  which  are  often  thus  cured.  Know- 
ing of  no  well-authenticated  case  in  which  ovarian  cyst  has  been  thus 
permanently  cured,  we  are  not  warranted  in  regarding  this  measure  as 
anything  more  than  a  valuable  diagnostic  means  and  a  palliative  resource, 
which  often  saves  life  when  it  is  threatened  by  one  of  the  consequences  of 
the  cystic  disease. 

In  case  the  contents  of  the  cyst  do  not  appear  to  be  those  of  true  ovarian 
cystoma,  but  present  the  characters  of  the  fluid  of  cyst  of  the  broad  liga- 
ment, tapping  may  be  practised  with  a  reasonable  hope  of  curative  results. 

The  circumstances  which  ordinarily  indicate  the  propriety  of  paracen- 
tesis as  a  palliative  measure  are,  rapid  accumulation  which  interferes  with 
some  important  function;  coexistence  of  ovarian  disease  with  pregnancy; 
solitary  character  of  the  cyst;  firm  adhesions  which  bind  the  tumor  down 
so  as  to  prohibit  a  more  radical  procedure;  great  doubt  as  to  diagnosis; 
or  constitutional  debility,  which  prevents  the  tolerance  of  a  more  serious 
operation.  The  operation  may  be  performed  through  the  abdominal,  vagi- 
nal, or  rectal  wall. 

Tapping  through  the  Abdominal  Wall. — The  patient  being  placed  upon 
the  side,  a  many-tailed  bandage,  such  as  is  employed  in  paracentesis  ab- 
dominis, is  passed  around  the  body.  Its  ends  being  held  by  assistants, 
traction  upon  them  makes  firm  pressure,  evacuates  the  tumor,  and  pre- 
vents syncope.  A  fold  of  skin  being  now  pinched  up  between  two  fingers, 
it  is  penetrated  by  a  lancet  or  bistoury  upon  the  linea  alba,  midway  be- 
tween the  svmphysis  pubis  and  umbilicus.  The  trocar  and  canula  are 
then  plunged  through  the  two  layers  of  peritoneum  and  the  wall  of  the 
cyst.  Through  the  canula  thus  introduced  a  flow  of  fluid  will  take  place, 
which,  if  such  an  instrument  as  that  represented  in  Fig.  254  be  employed, 
will  be  conducted  by  an  India-rubber  tube  attached  to  the  canula  into  a 
tub  placed  by  the  side  of  the  bed  upon  which  the  patient  lies.  The  free' 
extremity  of  this  tube  is  kept  carefully  immersed  in  water  in  the  tub,  to 
prevent  entrance  of  air  into  the  sac. 

Should  other  cysts  be  felt  through  the  abdominal  wall  after  emptying 
the  main  one,  the  canula  may  be  made  to  empty  them,  by  pressing  it 
firmly  against  them. 

The  following  rules  should  be  observed  in  abdominal  tapping  of  ovarian 
cysts,  for  it  is  highly  probable  that  a  strict  adherence  to  them  would  very 
favorably  affect  the  statistics  of  the  operation. 


TAPPING    TIIUOU'GII    THE    ABDOMINAL    WALL.  710 

1st.  Never  tap  while  the  patient  sits,  but  always  as.  she  lies  upon  the 
side  or  back. 

'2d.  Cut  the  skin  with  a  lancet,  and  employ  a  trocar  and  canula,  with 
tube  immersed  in  water,  so  as  to  prevent  entrance  of  air. 


tjjJCt^J^r---  — 


Fig.  255. 


3d.  When  the  fluid  withdrawn  is  viscid,  always  wash  out  the  cavity  of 
the  sac,  if  it  be  emptied,  with  warm,  carbolized  water. 

4th.  Should  there  be  oozing  of  blood  from  the  puncture,  pass  a  harelip 
pin  deeply  through  its  lips,  and  affix  a  figure-eight  ligature. 

oth.   Keep  the  patient  recumbent  and  very  quiet  for  two  or  three  days. 

Tapping  through  the  Wall  of  the  Vagina. — This  operation  has  been 
more  or  less  in  vogue  for  a  long  time.  According  to  Kiwisch,  it  was  first 
performed  by  Callisen  in  1775,  but  has  received  little  notice  until  modern 
times.  Velpeau1  declares  that  he  advised  it  in  1831,  and  that  it  was 
adopted  a  few  years  afterwards  by  Neumann  and  Recamier.  In  Germany 
it  has  of  late  years  been  frequently  resorted  to,  and  Scanzoni  gives  the  fol- 
lowing reasons  for  preferring  it  to  abdominal  paracentesis.  It  "  more 
often  produces  a  radical  cure  than  the  other  method  just  considered,  and 
that  especially  because  the  cyst,  opened  in  its  lowest  part,  can  empty  itself 
more  completely.  If  the  puncture  by  the  vagina  were  always  possible, 
the  abdominal  puncture  would  soon  entirely  disappear  from  chirurgical 
practice  ;  but  unfortunately,  this  is  not  the  case,  for  the  conditions  neces- 
sary for  this  operation  are  met  with  in  but  few  patients  ;  in  fact,  it  is  rare 
that  the  lower  portion  of  the  tumor  descends  sufficiently  low  into  the 
pelvis  to  be  accessible  to  vaginal  touch,  and,  furthermore,  in  many  cases 
where  the  tumor  can  be  reached,  it  does  not  present  in  its  lower  portion 
any  cavity  filled  with  liquid,  but  only  solid  masses  of  a  sarcomatous,  col- 
loid, or  cancerous  nature."  Kiwisch  declares  that  he  "  unconditionally" 
prefers  it  to  abdominal  tapping,  whenever  it  is  practicable. 

By  this  method,  the  advantages  of  which  are  thus  strongly  stated  by  the 
authorities  just  mentioned,  two  of  the  daggers  of  tapping,  secondary  escape 
of  fluid  into  the  peritoneum,  and  consequent  peritonitis,  are  unquestionably 

1  Diet,  de  Med.,  torn.  xxii.  p.  589. 


720  OVARIAN    CYSTS. 

lessened,  but  othets  are  as  surely  increased,  namely,  those  of  injury  to  por- 
tions of  the  intestine,  and  entrance  of  air  into  the  sac,  with  consequent 
decomposition  of  contents,  septicaemia,  and  inflammation  of  the  sac  walls. 
My  experience  with  the  method  is  not  large,  but  it  leads  me  to  agree  with 
Spencer  Wells  that,  "  as  a  rule,  air  enters  the  cyst,  the  opening  fills  up, 
and  the  fluid  remaining  in  the  cyst,  or  that  freshly  secreted,  putrefies. 
Suppurative  inflammation  of  the  lining  membrane  of  the  cyst  comes  on, 
and  is  accompanied  by  a  low  form  of  exhaustive  fever  or  pyaemia."  Where 
a  cyst  is  firmly  fixed  in  the  pelvis,  however,  this  method,  followed  by 
drainage  and  antiseptic  injections,  is  one  of  great  value. 

The  operation  is  thus  performed  :  the  bladder  and  rectum  having  been 
carefully  emptied,  and  the  patient  anaesthetized,  she  should  be  placed  upon 
a  table  in  the  position  for  lithotomy.  The  operator  then  introducing  the 
index,  or,  as  is  better,  the  index  and  middle  fingers  of  the  left  hand,  places 
them  against  the  most  dependent  and  accessible  part  of  the  tumor.  Upon 
the  finger  or  fingers,  a  canula  ten  inches  long  is  passed  up  and  pressed 
against  the  tumor,  the  point  of  the  trocar  being  drawn  in  a  little.  The 
operator  then  plunges  the  trocar  through  the  vaginal  walls  into  the  tumor, 
and  withdrawing  it  allows  the  fluid  to  flow  away  through  the  canula.  The 
patient  is  then  put  to  bed,  quieted  by  opium,  and  guarded  against  all 
influences  which  might  induce  inflammation  as  long  as  such  an  accident  is 
probable. 

Explorative  Incision Of  all  the  means  for  definite  and  certain  settle- 
ment of  the  question  of  diagnosis  in  abdominal  tumors,  I  esteem  explora- 
tive incision  most  highly.  As,  however,  it  involves  not  only  opening  the 
peritoneal  cavity,  but  usually  considerable  manipulation  of  its  contents,  it 
necessarily  involves  a  certain  amount  of  danger.  While  the  other  methods 
may  be  practised  several  days  or  even  weeks  before  the  operation  of  ova- 
riotomy, this  should  constitute,  or  rather  be  merged  into,  its  first  step.  If 
it  yield  information  which  makes  the  surgeon  decide  against  operation,  the 
opening  made  should  be  closed  ;  if  the  light  which  it  throws  upon  diagno- 
sis favors  the  radical  procedure,  the  incision  should  be  at  once  enlarged 
and  prolonged  into  the  final  abdominal  opening. 

Explorative  incision  should  be  thus  performed.  The  patient  having 
been  prepared  for  the  procedure  exactly  as  if  we  had  determined  upon  ova- 
riotomy, she  is  placed  upon  the  table  and  surrounded  by  assistants,  etc., 
as  in  the  case  of  the  radical  operation.  An  incision  is  then  made  by  the 
bistoury  upon  the  median  line,  one  inch  in  length.  This  is  carried  down 
to  the  tumor,  and  the  finger  is  at  once  gently  swept  over  this  in  every  di- 
rection, so  as  to  ascertain  its  character.  The  tumor  may  be  emptied  with 
a  very  small  trocar,  so  small  that  the  opening  made  may  be  readily  closed 
if  it  be  deemed  best  to  desist  from  radical  operation,  or  by  the  aspirator. 
If  the  sac  be  emptied  by  this  means,  the  hand  is  then  passed  into  the 
abdominal  cavity  and  complete  exploration  made.     If  it  be  not  completely 


TREATMENT.  721 

emptied,  a  sound  should  be  passed  into  the  uterus  and  two  fingers  or  the 
hand  carried  down  through  the  abdominal  opening  to  the  fundus  uteri,  to 
ascertain  as  accurately  as  possible  the  origin  and  attachments  of  the  solid 
mass.  In  case  abdominal  effusion  have  existed,  this  of  course  at  once 
flows  away,  and  any  growth  existing  in  the  abdomen  comes  within  the 
reach  of  the  finger. 

Before  leaving  this  part  of  my  subject  let  me  lay  before  the  reader  a  few 
rules,  the  observance  of  which  will  diminish  very  greatly  the  chances  of 
his  falling  into  errors  of  diagnosis  in  operating  for  ovarian  tumors. 

1st.  Never  perform  ovariotomy  without  carefully  exploring  the  uterus 
by  the  sound,  if  this  be  possible. 

2d.  Before  operation,  should  doubt  exist  as  to  diagnosis,  always  remove 
a  small  amount  of  fluid  by  the  hypodermic  syringe  or  aspirator  for  chemical 
and  microscopical  examination. 

3d.  If  any  doubt  whatever  exist  as  to  diagnosis,  anaesthetize  the  patient 
and  examine  carefully. 

4th.  If  doubt  still  exist,  empty  the  cyst  or  cysts  by  aspiration  or 
tapping. 

5th.  Should  all  doubts  not  be  cleared  up  at  the  moment  of  operation, 
begin  it  as  an  explorative  incision  and  proceed  or  not  as  instructed  by 
what  is  discovered. 

Spiegelberg1  makes  the  important  declaration  that  when  upon  drawing 
off  fluid  either  from  a  cyst  of  the  broad  ligament  or  an  ovarian  cyst,  it  is 
found  to  be  of  low  density  and  of  serous  nature,  it  may  be  taken  as  evi- 
dence that  the  cyst  wall  has  ceased  to  grow  actively,  and  is  merely  being 
distended  by  accumulation  of  its  contents.  He  opposes  operation  under 
such  circumstances,  declaring  that  emptying  the  cyst  will  of  itself  often 
effect  a  radical  cure. 

Treatment — The  medical  treatment  of  ovarian  dropsy  by  diuretics,  hy- 
dragogue  cathartics,  diaphoretics,  mercurials,  absorbents,  mineral  waters, 
etc.,  has  now  been  faithfully  tested  and  found  to  be  inefficacious.  After 
a  careful  search  through  the  records  of  the  subject,  one  is  forced  to  the 
conclusion  that  there  is  a  lack  of  evidence  substantiating  the  possibility 
of  the  accomplishment  of  absorption  by  these  means.  All  that  can  be 
anticipated  in  these  cases  from  medication  is  sustaining  the  nervous  and 
sanguineous  systems  by  tonics  and  stimulants ;  regulating  disordered 
functions  by  diaphoretics,  cathartics,  diuretics,  and  anti-emetics ;  and 
relieving  local  inflammations  by  the  ordinary  means  usually  resorted  to 
under  such  circumstances.  I  am  the  more  urgent  in  insisting  upon  the 
fact  of  the  inefficacy  of  constitutional  treatment,  because  I  so  often  meet 
with  fully  developed  cases  of  ovarian  dropsy  which  bear  evidence  of  a 
variety  of  attempts  by  cupping,  leeching,  inunction,  painting  with  iodine, 

1  Archiv  fur  Gynakologie,  vol.  xiv.  s.  175. 
46 


722  OVARIOTOMY. 

and  correspondingly  active  internal  treatment,  to  dissipate  the  accumu- 
lation. There  is  but  meagre  proof  extant  that  such  means  have  effected 
cures,  and  there  is  nothing  more  certain  than  that  they  lower  the  tone  of 
the  system  and  depreciate  the  vital  forces.  A  recognition  of  this  fact 
led  Dr.  W.  Hunter,  before  the  introduction  into  practice  of  the  present 
methods  of  surgical  treatment,  to  say  that,  "  the  patient  will  have  the  best 
chance  of  living  long  under  it  (ovarian  dropsy)  who  does  the  least  to  get 
rid  of  it." 

Not  only  is  it  to  surgery  alone  that  we  must  look  for  aid,  but  to  one 
surgical  procedure — ovariotomy.  Even  after  the  acceptance  of  ovariotomy 
as  an  operation,  the  medical  profession  strove,  and  very  properly,  too, 
against  its  universal  adoption  in  cases  of  ovarian  tumor,  and  endeavored 
to  discover  less  radical  processes  which  were  to  share  the  field  with  it. 
Thus  up  to  a  late  day  were  tried,  and  even  now,  in  rare  cases,  are  tried, 
tapping,  drainage,  incision,  and  injection  of  the  sac.  I  do  not  give  the 
details  of  these  procedures  here,  for  the  reason  that  I  question  the  pro- 
priety of  their  adoption.  In  the  present  state  of  our  knowledge,  whether 
the  tumor  be  large  or  small,  simple  or  complex,  the  attempt  to  employ 
other  curative  means  than  ovariotomy  can  scarcely  be  regarded  as  warrant- 
able, in  view  of  the  dangers  attaching  to  them  and  their  uncertainty  of 
success,  and,  on  the  other  hand,  the  hope  of  good  results  which  is  held 
out  if  the  patient  is  sustained  until  complete  extirpation  can  be  accom- 
plished. 


CHAPTER    XLIX. 

OVARIOTOMY. 

Definition. — Ovariotomy  consists  in  the  extirpation  of  the  diseased 
ovaries. 

History. — The  history  of  the  operation  goes  back  only  to  a  very  recent 
date.  It  has  become  customary  for  those  who  have  written  upon  it  to 
cite  ancient  authors  to  prove  that  even  as  long  ago  as  the  time  of  the  early 
Greeks  the  ovaries  were  often  removed  in  the  inferior  animals  as  is  done 
in  our  own  time.  The  writings  of  Aristotle  put  this  beyond  question. 
It  is  even  asserted  that  among  the  Lydians  castration  of  the  human  female 
was  practised  in  order  to  enable  them  to  serve  as  eunuchs.  In  more 
recent  periods,  we  are  told  by  Wierus  that  a  Hungarian  swineherd,  in- 
censed by  the  lasciviousness  of  his  daughter,  removed  her  ovaries,  in  hope 
of  reformation,  after  the  manner  in  which  he  was  in  the  habit  of  spaying 
his  swine.     Towards  the  close  of  the  eighteenth  century  both  ovaries. 


HISTORY.  723 

which  had  descended  into  the  inguinal  canals,  were  removed  hy  Dr.  Per- 
cival  Pott,  of  England.  But  all  this,  though  interesting  as  a  matter  of 
physiology,  has  little  to  do  with  the  operation  of  ovariotomy,  according  to 
the  true  signification  of  the  term.  In  the  one  case  a  minute  and  healthy 
gland,  which  is  sparsely  supplied  with  blood,  was  removed  from  a  healthy 
peritoneal  cavity.  In  the  other  a  huge  sac,  which  is  supplied  by  large 
bloodvessels,  and  has  in  many  instances  contracted  adhesions  to  a  diseased 
peritoneum,  requires  extirpation. 

The  idea  of  removing  large  ovarian  cysts,  even,  is  not  new,  since  it 
was  discussed  in  1685  by  SchorkopfF,  in  1722  by  Schlenker,  in  1731  by 
Willius,  in  1751  by  Peyer,  and  in  1752  by  Targioni.  In  1758,  Delaporte 
even  went  so  far  as  formally  to  propose  the  operation  to  the  Royal  Academy 
of  Surgery.  As  the  eighteenth  century  approached  its  close,  the  sugges- 
tions of  the  writers  already  mentioned  were  not  forgotten,  but  were  from 
time  to  time  repeated  ;  among  others  by  John  Hunter  in  1787,  and  later 
still  by  William  Hunter.  In  1798,  Chambon  ventured  to  prophesy  that 
it  would  in  time  become  a  recognized  resource  in  surgery  ;  and  in  1808,1 
Samuel  d'Escher,  a  student  of  Montpellier,  proposed  a  specific  plan  for  its 
performance  based  upon  the  teachings'  of  one  of  his  masters,  M.  Thumin. 

In  178G,  one  observer  stood  upon  the  very  verge  of  the  great  discovery, 
very  much  nearer  than  Laumonier,  by  some  supposed  to  be  the  discoverer, 
ever  did,  and  yet  failed  to  systematize  it  as  a  surgical  resource.  Like 
many  a  man  before  and  since  his  time,  he  recognized  and  appreciated  a 
fact,  but  failed  to  connect  this  with  a  law.  The  following  is  a  quotation 
from  a  work  written  by  Thomas  Kirkland,  an  Englishman,  and  published 
in  London  in  1786.  It  is  entitled,  "An  Inquiry  into  the  Present  State 
of  Medical  Surgerv."2 

"A  woman,  betwixt  twenty  and  thirty  years  of  age,  had  been  tapped 
twice  for  an  ascites,  and  a  large  quantity  of  water  taken  away  at  each 
time  ;  but  after  the  last  operation  the  puncture  did  not  heal,  and,  in  a  little 
time,  a  substance  the}r  did  not  understand  protruding,  I  was  desired  to  see 
her.  It  was  evidently  a  part  of  a  cyst,  and,  as  it  had  already  dilated  the 
sore,  I  persuaded  her  to  let  it  alone  till  the  opening  became  larger,  in  hope 
of  a  better  opportunity  of  affording  relief.  Accordingly,  in  ten  days  or  a 
fortnight  the  protrusion  was  much  larger,  and  by  the  help  of  a  dry  cloth  a 
cyst,  that  would  contain  five  or  six  gallons  of  water,  was  gradually  ex- 
tracted. More  than  a  quart  of  matter  immediately  followed,  and  more  was 
daily  discharged  for  some  time,  }-et  the  woman  recovered  without  further 
trouble  than  keeping  the  parts  clean,  and  afterwards  bore  several  children." 

Later  on  in  his  work  he  says  : — 

"  We  have  given  an  instance,  p.  195,  where  a  cyst  being  taken  away 
cured  an  ascites  ;  and,  seeing  medicines  do  not  avail  in  encysted  dropsies 

1  Wieland  and  Dnhrisay,  French  translation  of  Churchill  on  Dis.  of  Women. 

2  Med.  Record,  June  15,  1867,  from  Exchange. 


724  OVARIOTOMY. 

of  the  abdomen,  is  it  not  worth  our  while  to  consider  whether,  when  they 
are  unconnected  with  the  adjacent  parts,  after  taking  away  the  water,  the 
patient  might  not  sometimes  be  cured  by  enlarging  the  puncture,  pressing 
the  cyst  forward,  and  drawing  it  out  V" 

He  then  proceeds  to  examine  the  difficulties  in  the  way  and  the  objec- 
tions which  may  be  brought  against  the  operation,  and  thus  concludes  : — 

"  At  present,  I  offer  these  hints  to  those  who  think  the  subject  deserving 
attention,  and  time  will  probably  determine  the  question." 

Thus,  as  we  advance  from  more  remote  periods  to  the  beginning  of  the 
nineteenth  century,  we  find  the  minds  of  physicians  being  gradually  pre- 
pared for  the  reception  of  ovariotomy,  as  its  consummation  was  step  by 
step  approached.  But  all  that  we  find  accomplished  up  to  this  time  is  the 
promulgation  of  ideas,  prophecies,  and  propositions,  and  the  performance 
of  accidental  operations,  or  of  those  upon  healthy  ovaries. 

In  1809,  the  first  real  case  of  ovariotomy  ever  undertaken  was  success- 
fully performed  by  Dr.  Ephraim  McDowell,  of  Kentucky.  His  first  case 
was  successful,  the  patient  living  twenty-five  years  afterwards.  Subse- 
quently he  operated  thirteen  times,  Vith  eight  favorable  results.  It  may 
confidently  be  asserted  that  the  history  of  no  operation  has  been  more 
thoroughly  sifted  than  this,  and  that,  up  to  the  present  time,  nothing  can 
be  clearer  than  the  fact  that  to  McDowell  belongs  the  credit  of  priority  of 
performance.  It  is  interesting  to  examine  the  competitive  claims  which 
have  been  put  forward  in  reference  to  the  matter.  First,  in  chronological 
order,  is  that  of  Dr.  Houstoun,1  of  Scotland,  who  operated  in  1701,  and 
whose  case,  says  Mr.  "Wells,2  makes  it  "appear  that  ovariotomy  originated 
with  British  surgery,  on  British  ground."  This  statement  will  excite 
wonder,  and  the  claims  of  the  operator  fail  to  attract  attention  when  it  is 
stated  that  nowhere  does  Houstoun  claim  to  have  removed  the  cyst,  or 
even  a  part  of  it.  He  merely  treated  a  case  of  ovarian  cyst  successfully 
by  incision. 

The  second  is  that  of  Laumonier,  of  France.  Of  him  Baker  Brown 
says:  "The  first  who  attempted  extirpation  appears  to  have  been  Aumo- 
nier,  of  Rouen,  in  1782,  and  he  was  successful."  In  this  statement,  as 
Dr.  Parvin  has  pointed  out,  Mr.  Brown  was  wrong  in  three  points:  first, 
as  to  the  fact;  second,  as  to  the  name  of  the  operator;  and  third,  as  to  the 
date.  The  supposed  ovariotomy  was  performed  in  1770,  by  Laumonier, 
and  was  really  the  opening  of  a  pelvic  abscess. 

The  third  is  that  of  Dzondi,  of  Halle.  As  the  patient  was  a  boy,  the 
claim  requires  no  further  consideration. 

In  1821.  Dr.  Nathan  Smith,  of  this  country,  operated  successfully.  In 
1823  Dr.  Lizars  endeavored  to  introduce  the  operation  into  Scotland,  and 

1  Amer.  Jonrn.  of  Med.  Sciences,  vol.  vii.,  1849,  p.  534.        «  Op.  cit.,  p.  299. 


HISTORY.  726 

operated  four  times,  but  his  results  were  bad.  In  one  case  the  tumor  was 
uterine  and  was  not  removed  ;  in  one  no  tumor  could  be  discovered  after 
abdominal  section  ;  and  one  of  ^he  two  cases  upon  which  ovariotomy  was 
performed  died. 

Since  this  period,  Atlee,  Peaslee,  Kimball,  and  Dunlap  have  been  most 
influential  in  establishing  the  operation  in  America.  In  England,  Dr. 
Charles  Clay,  in  1840,  pressed  it  upon  the  notice  of  the  profession,  and 
he  was  soon  ably  sustained  by  Lane,  Wells,  Keith,  Bryant,  Baker  Brown, 
and  many  others,  whose  names  have  become  famous  in  connection  with  it. 

"  It  is  only  within  the  last  five  years,"  says  Grenser,  writing  in  1871, 
"  that  much  progress  has  been  made  in  Germany  in  this  operation." 
Unfortunately,  for  many  years  insuccess  appeared  to  attend  it,  and  thus 
the  voices  of  the  most  eminent  and  authoritative  were  raised  against  it. 
Of  the  first  three  patients  ever  operated  upon  there  (by  Chrysmar,  in 
Wurtemberg),  two  died.  Chrysmar  commenced  operating  in  1819,  and 
his  results  were  certainly  not  such  as  to  popularize  a  new  and  dangerous 
procedure.  In  1828  the  adverse  criticism  of  the  great  Dieffenbach  was 
pronounced  in  these  strong  terms  :  "  Whoever1  considers  the  opening  of 
the  abdominal  cavity  as  a  light  matter,  and,  as  Lizars  seems  to  believe, 
that  the  difficulties  are  small,  whoever  thinks  that  this  operation  is  accom- 
panied by  no  more  dangers  than  other  operations,  must  be  very  thought- 
less;  for  me,  my  one  case  is  sufficient."  The  "one  case"  to  which  he 
refers,  and  from  which  he  drew  so  illogical  and  hasty  a  conclusion,  was 
an  incomplete  operation.  In  spite  of  the  adverse  weight  of  this  opinion, 
in  1835  Quittenbaum,  in  1841  Stilling,  and  in  1851  Martin,  operated  in 
a  few  cases,  and  with  varying  success.  Writing  of  the  operation  at  this 
time,  when  overclouded  by  repeated  insuccesses,  it  had  failed  to  command 
the  confidence  of  the  profession,  Grenser  says  :  "  Most  of  the  ovariotomies 
performed  within  the  last  forty  years  had  a  fatal  termination,  and  as  a 
consequence  reliance  could  not  be  felt  in  it,  and  confidence  in  it  was  alto- 
gether shattered  when  the  celebrated  Dieffenbach  took  ground  against  the 
operation."  Dieffenbach's  opinion  in  1828  has  been  given  ;  let  us  see 
how  the  experience  of  twenty  years  affected  it.  In  1848  he  wrote  :  "  The 
operation  does  not  benefit  either  patient  or  physician  ;  the  idea  of  opening 
into  the  abdomen  of  a  sick,  cachectic  woman,  affected  with  a  hard  tumor 
of  the  ovary,  or  even  employing  Lizars'  method  with  cross-incisions,  in 
order  to  remove  the  tumor  by  force,  seems  neither  reasonable  nor  useful." 
He  modified  his  opinion  somewhat  where  the  tumor  was  fluid,  of  small 
size,  and  movable.  Thus  wrote  the  great  surgical  light  of  Germany,  and 
while  he  wrote  American  and  English  surgeons  were  gaining  great  results 
for  humanity  and  for  science  in  this  same  field.  It  must  not  be  supposed 
that  even  in  his  own  country  advances  were  not  being  made,  for  Stilling, 

1  Grenser,  Report  on  Ovariotomy  in  Germany. 


726  OVARIOTOMY. 

Biiring,  and  others  were  carrying  on  the  work.  In  1850  the  latter  an- 
nounced an  important  advance,  namely,  that  adhesions  should  not  be 
considered  as  a  contra-indication  to  removal. 

In  1852  Edward  Martin  declared  that  the  question  was  no  longer  as  to 
the  propriety  and  efficiency  of  ovariotomy,  but  of  circumstances  favorable 
to  success.  Martin's  rules  for  operating,  read  even  by  our  present  lights, 
are  most  of  them  excellent. 

Ahout  this  time  the  voice  of  Kiwisch  was  raised  against  the  operation. 
He1  collected  the  statistics  of  5-1  cases,  of  which  51  ended  fatally,  and 
concluded  that  certainly  over  half  of  all  submitted  to  operation  died.  It 
was  soon  after  this  that  Scanzoni  and  Gustav  Simon  gave  their  evidence 
against  the  operation,  and  increased  its  disfavor  to  such  a  degree  that,  as 
Grenser  says,  "  its  very  existence  was  threatened."  This  opposition 
seems  to  have  lasted  up  to  1864,  when  the  tide  appeared  to  turn  in  its 
favor,  and  it  soon  numbered  among  its  advocates  Breslau,  Gusserow, 
Hildebrandt,  Spiegelberg,  Martin,  Stilling,  Veit,  Wagner,  and  Billroth. 
Grenser  collected  in  1871  the  statistics  of  129  operations  performed  in 
Germany,  of  which  60,  a  little  less  than  half,  recovered.  When  these 
results  are  compared  with  English  and  American  statistics  of  that  period, 
they  show  that  Germany  had  much  to  make  up.  That  she  has  done  this 
is  proved  by  the  excellent  results  obtained  by  Schroeder  and  other  operators 
of  the  present  time,  and  to-day  it  must  be  conceded  that  in  this  department 
of  surgery  she  stands  fully  abreast  with  other  countries. 

According  to  Grenser  we  owe  to  Germany  two  of  the  most  important  of 
the  improvements  which  have  taken  place  in  the  operation  since  the  days 
of  McDowell  :  first,  the  adoption  of  the  short  incision  and  tapping  the  sac 
in  situ,  which  originated  with  Quittenhaum  ;  second,  the  external  treat- 
ment of  the  pedicle,  which  he  declares  was  first  resorted  to  and  its  advan- 
tages insisted  upon  by  Stilling  in  1841,  and  not  by  Duffin  in  1850.  In 
1849,  Martin  first  secured  the  pedicle  in  the  lips  of  the  wound.  There  are 
other  advances  which  have  heen  made  in  Germany  ;  but  1  mention  only 
those  which  have  had  a  decided  influence  on  the  operation. 

Into  France  the  operation  was  introduced,  or  as  some  French*  writers 
express  it,  "reintroduced,"  by  Dr.  Woyerkowski,  in  1844.  It  was  sub- 
sequently performed  by  Vaullegeard,  in  1847,  and  later  still  by  Nelaton, 
Maisonneuve,  Jobert,  Demarquay,  and  other  surgeons  of  Paris.  The  re- 
sults of  these  attempts,  however,  had  the  effect  of  casting  discredit  on  the 
operation,  from  which  it  is  only  now  emerging,  thanks  to  the  writings  of 
Jules  Worms,  Oilier,  Labalhary,  Vegas,  and  more  especially  to  those  of 
Koeberle,  of  Strasbourg.  When  it  is  stated  that  all  these  writers  have 
published  since  1862,  it  will  be  appreciated  how  recent  is  the  favorable 
reception  of  the  operation  in  France. 

1  Grenser,  loc.  cit. 

8  Wieland  and  Dubrisay,  the  French  translators  of  Churchill. 


VARIETIES  —  DANGERS.  727 

M.  Boinet,  in  18G7,  read  an  essay1  before  the  Academy  of  Medicine, 
strongly  advocating  it,  and  "  reprobating  the  timidity  of  French  surgeons 
who  have  so  long  recoiled  before  it." 

Up  to  July,  1868,  Pean,  of  Paris,  had  had  seven  recoveries  out  of  ten 
cases,  and  in  1870  and  '71,  out  of  thirty-two  operations,  twenty-six  re- 
coveries took  place.  In  1873,  he  wrote  a  work  upon  Hysterotomy  for 
Fibroids  and  Fibro- Cysts,  in  which  he  claims  seven  recoveries  for  nine 
operations.  Nothing  could  more  surely  mark  the  advance  of  the  operation, 
as  well  as  the  rapidly  increasing  boldness  and  skill  of  French  surgeons, 
than  this  announcement. 

It  is  needless  to  point  out  the  fact  that  to-day  all  opposition  to  the  ope- 
ration has  disappeared,  and  that  in  every  civilized  country  of  the  globe  it 
stands  among  the  proudest  achievements  of  surgery. 

In  concluding  the  history  of  ovariotomy,  it  may  be  said  that  the  concep- 
tion of  the  operation  in  all  its  steps  is  over  a  hundred  years  old,  and  is  of 
European  origin  ;  that  for  its  accomplishment  we  are  indebted  to  what  M. 
Piorry  once  styled,  "  une  audace  Americaine,"  which  was  supplied  by 
Ephraim  McDowell ;  and  that  many  of  the  important  improvements  which 
have  since  been  introduced,  we  owe  to  Great  Britain.  Pre-eminently  an 
Anglo-American  procedure,  it  has  only  within  the  last  decade  assumed  its 
legitimate  place  in  Germany  and  France,  but  in  both  countries  it  is  not 
merely  maintaining  itself,  but  being  improved  and  advanced  towards  per- 
fection. 

Varieties — There  are  two  forms  of  the  operation  :  one,  abdominal  ova- 
riotomy, in  which  the  cyst  is  removed  through  the  incised  abdominal  walls; 
the  other,  vaginal  ovariotomy,  in  which  a  small  cyst  is  removed  by  in- 
cision through  the  fornix  vaginae.  Incomplete  cases,  or  those  in  which  only 
a  portion  of  the  sac  is  removed,  have  also  been  grouped  under  the  first 
head,  but  very  improperly  so,  for  less  than  complete  removal  constitutes 
an  entirely  different  operation,  which  is  known  as  partial  excision. 

Dangers — The  dangers  which  attend  it  are  numerous  and  grave.  The 
following  table,  constructed  by  Dr.  Peaslee  upon  the  post-mortem  evidence 
of  50  cases,  will  exhibit  them  at  a  glance: — 


Peritonitis 

.     12 

Strangulation 

of    intestine    in 

Septicaemia 

.       9 

wound     . 

.     1 

Shock  or  collapse 

.       7 

Diarrhoea    . 

.     1 

Exhaustion 

7 

Erysipelas  . 

.     1 

Shock  and  septicemia 

.       1 

Tetanus 

.     1 

Hemorrhage 

.       9 

Ulceration  through  bladder     1 

Unknown    . 

.     9 

It  will  be  seen  from  this  table  that  peritonitis  destroyed  one-quarter  of 
all  who  died  from  the  operation  ;  and  septicaemia,  or  absorption  of  putrid 
material,  one-sixth.  After  these  causes  followed  those  directly  resulting 
from  the  depressing  influence  of  the  operation  upon  the  nervous  system. 

•  N.  Y.  Med.  Record,  July,  1867. 


728  OVARIOTOMY. 

Dr.  John  Clay  makes  the  following  analysis  of  the  causes  of  death  in 
150  fatal  cases,  reported  in  his  tables : — 

Shock  or  collapse 25 

Hemorrhage  ........  24 

Peritonitis      ........  64 

Phlebitis 1 

Tetanus 2 

Intestinal  affections 6 

Abscess .  3 

Chest  diseases 4 

Congestion  of  brain 1 

Diabetes          ........  1 

Not  stated 19 

150 

That  in  these  lists  many  cases  of  septicaemia  ending  in  peritonitis  are 
catalogued  as  peritonitis,  I  think  is  proved  by  the  light  which  we  now 
have  on  the  subject.  My  own  observation  would  lead  me  to  put  the  causes 
of  fatal  issue  after  ovariotomy  in  the  following  order  as  to  frequency  and 
importance  : — 

Septica3mia ; 

Peritonitis ; 

Hemorrhage  ; 

Shock. 
The  first  of-  these  is  the  great  evil  to  be  feared,  and  combined  with  the 
second  causes  more  deaths  than  all  the  other  causes  added  together  and 
multiplied  by  ten. 

Statistics — So  hard  was  the  struggle  of  ovariotomy  for  existence,  so 
vigorous  and  malign  the  attacks  made  against  it  by  the  leaders  of  profes- 
sional opinion  all  over  the  world,  and  so  delicate  the  position  of  those  bold 
and  enterprising  men  who  in  the  United  States  and  England  still  clung 
to  its  fortunes,  that  up  to  a  very  recent  period  it  was  necessary  to  deal 
fully  with  statistical  evidence  endorsing  it.  That  time  has  now  happily 
passed,  ovariotomy  now  standing  upon  a  basis  every  whit  as  firm  as  that 
of  amputation  of  the  leg  or  any  other  operation  of  general  surgery.  Then, 
too,  a  new  era  has  dawned  upon  ovariotomy  within  the  past  five  years 
which  will  almost  surely  greatly  improve  the  statistics  of  the  future.  An- 
tiseptic surgery  applied  to  this  operation  has  already  accomplished  a  great 
deal ;  it  will  in  all  probability  do  in  the  future  much  more  than  it  has  done 
thus  far. 

Conditions  favorable  to  the  operation — 

Clearness  and  certainty  of  diagnosis  ; 

Good  constitutional  condition  ; 

Patient  being  hopeful  and  desirous  of  operation  ; 

Paucilocular  character  of  cyst ; 


CONDITIONS  FAVORABLE  TO  THE  OPERATION.     729 

Absence  of  much  solid  matter  in  its  structure  ; 

Abdominal  walls  not  very  thick  ; 

Absence  of  strong  pelvic  adhesions. 
The  possibility  of  error  in  diagnosis  has  been  already  sufficiently  dwelt 
upon.  The  importance  of  clearly  understanding  the  nature  of  the  tumor 
cannot  be  over-estimated.  The  operator  should,  by  repeated  and  most 
careful  examinations,  alone  or  with  counsel,  endeavor  to  determine  all 
the  features  of  the  case,  not  merely  the  fact  that  a  tumor  exists,  but  that 
it  is  ovarian  and  not  uterine,  that  pregnancy  does  not  exist  with  it,  that 
it  is  not  cancerous,  that  its  contents  are  fluid,  and  that  the  fluid  felt  is  all 
ovarian  and  none  of  it  abdominal.  In  two  cases  I  have,  in  company  with 
a  number  of  others  who  consulted  with  me,  been  greatly  deceived.  In 
one  case,  when  upon  the  point  of  operating  upon  a  large,  multilocular 
tumor,  the  patient  lying  on  the  table,  I  discovered  the  coexistence  of 
pregnancy  in  the  fifth  month.  In  another,  which  I  supposed  to  be  a 
huge  ovarian  tumor,  upon  cutting  through  the  abdominal  walls,  an  im- 
mense amount  of  fluid  escaped,  leaving  for  removal  a  solid  tumor  of  the 
ovary  not  larger  than  the  adult  head.  Cases  are  on  record  in  which  sur- 
geons of  great  experience  and  skill  have  cut  down  upon  uterine  fibroids, 
cysts  of  the  kidneys,  the  pregnant  uterus,  and  other  abdominal  enlarge- 
ments, under  the  impression  that  ovarian  cysts  existed,  and  instances  have 
occurred  in  which  abdominal  section  discovered  no  tumor  of  any  kind,  the 
operator  having  been  deceived  by  tympanites. 

As  to  the  period  at  which  the  operation  should  be  undertaken,  there  is, 
and  probably  always  will  be,  a  great  deal  of  diversity  of  opinion.  As  the 
decision  of  this  point  will  always  involve  a  great  deal  of  responsibility  on 
the  part  of  the  operator,  it  will  not  be  without  interest  to  refer  to  the 
views  of  weighty  authorities.  Baker  Brown  operated  quite  early,  as  soon 
as  the  diagnosis  was  fully  established,  in  order  to  avoid  changes  in  the 
cyst  and  peritoneum.  Peaslee  and  Tyler  Smith  waited  for  some  degree 
of  impairment  of  health  and  emaciation,  as  does  Keith  likewise.  Wells 
operates  when  the  patient  cannot  walk  a  mile  without  difficulty.  Bryant 
does  so  when  the  tumor,  by  its  size,  inconveniences  the  patient  and  inter- 
feres with  her  domestic  duties;  while  Greenhalgh  postpones  the  operation 
as  Ions  as  it  is  justifiable,  in  order  to  secure  changes  in  the  peritoneum 
which  will  render  it  less  liable  to  traumatic  peritonitis. 

It  appears  to  me  that  the  general  rule  should  be  this  :  if  a  small  cyst 
be  discovered  which  is  removable  by  the  vagina,  it  should  be  removed  as 
soon  as  possible,  while  one  too  large  for  this  should  be  interfered  with 
when  it  is  evident  that  the  patient  is  failing  in  strength,  and  becoming 
emaciated,  depressed,  and  nervous.  To  this  rule  there  are,  however, 
marked  exceptions.  In  a  patient  of  calm,  philosophic  mind,  who  does 
not  chafe  at  the  knowledge  that  a  tumor  exists,  delay  is  often  advisable  in 
the  case  of  a  tumor  which,  in  a  nervous,  fretful,  cowardly  woman,  who  is 


730 


OVARIOTOMY, 


rendered  almost  insane  by  such  knowledge,  should  be  removed  at  a  much 
earlier  period. 

The  following  table,  constructed  by  Dr.  J.  Clay,  of  299  cases  in  which 
the  general  health  was  ascertained,  displays  the  important  fact  that  even 
great  emaciation  does  not  produce  a  very  unfavorable  result : — 


Class  of  cases. 

Health  good. 

Health 
impaired. 

Much 
emaciated. 

Complicated 

with  other 

disease. 

Complicated 

with 
pregnancy. 

Successful   .... 
Unsuccessful    .     .     . 

21 
21 

17 
25 

47 
46 

21 
27 

2 
2 

Total    .     .     . 

42 

42 

93 

48 

4 

The  mental  state  of  the  patient  has  so  marked  an  influence  on  the  result 
that  operators  agree  that  a  depressed  and  apprehensive  condition  commonly 
produces  an  unfavorable  issue. 

The  greater  the  amount  of  solid  matter  in  an  ovarian  tumor,  the  more 
favorable  will  be  the  prognosis  as  to  rate  of  growth  and  the  more  unfavor- 
able as  to  cure. 

The  following  is  Dr.  Clay's  table  in  reference  to  the  character  of  the 
tumor : — 


Class  of  cases. 

Monocystic. 

Polycystic. 

Solid. 

Small. 

Medium. 

14 

17 

Large. 

Successful     .     .     . 
Unsuccessful     .     . 

19 
25 

66 
106 

8 
13 

4 

3 

30 
18 

Total .     .     . 

44 

172 

21 

7 

31 

48 

The  greater  the  thickness  of  the  abdominal  walls,  the  more  extensive 
will  be  the  surface  which  must  unite  to  effect  closure  of  the  abdominal 
opening,  and  the  greater  the  probability  of  suppuration  occurring  between 
the  lips  of  the  wound  and  pus  pouring  into  the  peritoneum. 

The  presence  of  adhesions  to  the  abdominal  viscera  greatly  complicates 
the  case,  but,  as  this  can  be  determined  only  after  abdominal  section,  its 
consideration  will  be  postponed  until  that  point  in  the  description  of  the 
operation  is  reached. 

Conditions  unfavorable  to  the  operation — The  following  circumstances, 
although  unfavorable  to  the  operation,  do  not  contraindicate  it,  unless 
they  exist  in  the  most  exaggerated  degree  : — 

Obscurity  as  to  diagnosis; 

Great  constitutional  impairment; 

Gastric  or  intestinal  disorder; 

Depression  of  spirits; 

Presence  of  much  solid  matter  in  tumor; 


VAGINAL    OVARIOTOMY. 


731 


Extensive  and  firm  adhesions  to  viscera; 

Complication  with  other  diseases; 

Great  thickness  of  abdominal  walls. 
Vaginal  Ovariotomy. — In  certain  cases,  rare  ones  T  admit,  in  which 
a  tumor  not  larger  than  the  head  of  a  child  a  year  old  falls  down  into 
Douglas's  cul-de-sac,  it  will  be  possible  to  cut  through  the  vagina,  seize 
the  sac,  draw  it  down,  ligate  the  pedicle,  and  fasten  it  by  suture  in  the 
lips  of  the  vaginal  opening.  If  this  can  be  done,  a  great  deal  of  risk 
will  be  avoided,  and  the  patient  spared  a  lengthy  period  of  suspense,  with 
the  prospect  of  a  serious  capital  operation  at  the  end.  I  will  lay  the  steps 
of  this  operation  before  the  reader  by  relating  the  first  case  in  which  it 
was  resorted  to  by  myself. 

The  patient  having  been  etherized  was  placed  in  the  knee-elbow  posi- 
tion, and  secured  upon  the  apparatus  of  Dr.  Bozeman.  This  apparatus 
not  only  completely  fixes  the  patient  in  this  position,  by  straps  and  braces, 
but  makes  the  position  perfectly  comfortable  for  any  length  of  time,  and 
also  favors  the  administration  of  an  anaesthetic.     It  is  shown  in  Fig:.  256. 


Fio.  256. 


ozcmau's  securing  apparatus. 


To  prevent  all  possibility  of  the  rectum  falling  into  the  line  of  incision, 
a  rectal  bougie  was  inserted  for  about  five  inches.  Sims's  speculum  being 
introduced,  and  the  perineum  and  posterior  vaginal  wall  lifted,  I  caught 
the  fornix  vaginas  between  the  cervix  and  rectum  with  a  tenaculum,  drew 
it  well  down,  and  with  a  pair  of  long-handled  scissors,  one  limb  of  which 
was  placed  against  the  rectum  and  the  other  against  the  cervix,  cut  into 
the  peritoneum  at  one  stroke. 

The  first  step  of  the  operation  being  accomplished,  I  proceeded  to 
the  second.  The  patient's  position  was  changed  to  the  dorsal  decubitus, 
and  passing  my  finger  through  the  vaginal  incision,  I  distinctly  touched 


732  OVARIOTOMY. 

the  tumor,  which  had  fallen  into  the  pelvis,  and  fastened  a  tenaculum  in 
its  wall.  With  a  small  trocar  I  punctured,  one  after  the  other,  three  cysts, 
which  gave  vent  to  about  six  or  eight  ounces  of  fluid  which  looked  pre- 
cisely like  vomited  bile.  Drawing  upon  the  cyst,  it  then  passed  without 
difficulty  into  the  vagina. 

For  the  third  step  of  the  operation  the  position  of  the  patient  was  again 
changed.  She  was  now  placed  in  Sims's  position  on  the  left  side  and  his 
speculum  introduced.  Passing  through  the  pedicle  at  its  point  of  exit 
from  the  vaginal  roof,  a  needle,  armed  with  a  strong,  double  silk  ligature, 
I  tied  each  half  of  the  penetrated  tissue  and  cut  off"  the  cyst  and  liga- 
ture. The  cul-de-sac  of  Douglas  was  then  sponged,  the  pedicle  returned 
to  the  abdominal  cavity,  the  incision  in  the  vagina  closed  by  one  silver 
suture,  and  the  patient  put  to  bed. 

The  entire  operation  occupied  thirty-five  minutes,  and  presented  no 
difficulties  other  than  those  slight  ones  incidental  to  ligature  of  a  pedicle 
at  some  distance  up  the  vagina. 

The  only  variation  which  increased  experience  would  prompt  in  this 
course  would  be  the  fixing  of  the  ligated  pedicle  in  the  vaginal  wound  by 
silver  suture,  instead  of  returning  it  to  the  abdomen. 

It  is  not  my  belief  that  the  scope  of  this  plan  of  performing  ovariotomy 
will  ever  be  very  great ;  but  I  think  that  in  cysts  of  small  size,  which  are 
unattached,  it  will  offer  a  valuable  resource  for  the  avoidance  of  years  of 
mental  suffering  while  the  disease  is  progressing,  and  of  the  capital  opera- 
tion of  abdominal  ovariotomy  in  the  end,  with  all  its  attendant  dangers 
and  uncertainties.  Even  in  a  doubtful  case,  vaginal  ovariotomy  may  be 
resorted  to  as  a  tentative  measure,  which,  in  the  event  of  failure  from 
attachment  of  the  cyst,  would  in  all  probability  be  recovered  from. 

I  should  urge  upon  any  one  who  determines  to  essay  it,  not  to  trust  to 
his  general  knowledge  of  the  anatomy  of  the  fornix  vaginae  and  peritoneum, 
but  to  rehearse  the  first  step  of  the  operation  upon  the  cadaver  before 
attempting  it  upon  his  patient.  There  is  often  considerable  space  between 
the  roof  of  the  vagina  and  the  floor  of  the  peritoneum,  and  it  usually 
requires  two  strokes  of  the  scissors  to  penetrate  the  abdominal  cavity. 
The  first  severs  the  vagina;  then  through  this  opening  a  tenaculum  should 
be  passed,  and  the  peritoneum  drawn  down  and  opened.  In  thin  women, 
if  the  fornix  be  well  drawn  down  by  a  tenaculum,  one  stroke  will  often 
open  the  peritoneum. 

This  operation  has  been  now  performed  a  number  of  times  with  the  best 
results  by  Gilmore,  Hamilton,  Goodell,  and  others.  I  feel  sure  that  it 
has  before  it  a  future  of  usefulness  for  the  following  reasons.  It  is  fully  as 
easy  of  performance  as  abdominal  ovariotomy;  is  evidently  attended  by 
much  less  danger;  holds  out  to  the  patient  the  opportunity  of  avoiding 
many  weary  months  of  suspense  in  anticipation  of  that  more  grave  pro- 


ABDOMINAL    OVARIOTOMY.  733 

cedure  ;  is  equally  applicable  to  multilocular  and  to  unilocular  cysts  ;  and 
gives  abundant  facility  for  securing  the  pedicle. 

Abdominal  Ovariotomy I  have  already  expressed  my  belief  that  only 

a  limited  number  of  cases  will  be  susceptible  of  the  procedure  just  de- 
scribed. The  great  resource  in  ovarian  tumors  is  the  ordinary  operation 
of  ovariotomy  by  the  abdomen. 

Previous  to  the  operation  the  patient  should  be  put  upon  a  tonic  course. 
Generous  diet,  iron,  quinine,  fresh  air,  cheerful  surroundings,  and  gentle 
exercise  should,  unless  impracticable  from  some  peculiarity  of  the  case,  be 
prescribed.  A  visit  to  the  country  or  some  quiet  watering  place  will  prove 
of  great  advantage.  Above  all  things,  the  mind  of  the  patient  should  be 
made  calm  and  cheerful,  and  every  hope  as  to  the  result  of  the  operation 
encouraged.  After  a  candid  statement  of  the  chances  of  success  has  been 
rendered  her  as  material  upon  which  to  base  her  determination  to  accept 
or  reject  the  operation,  no  doubt  ought  thenceforth  to  be  expressed  as  to 
the  result  by  physician  or  friends. 

The  operation  should  be  performed  in  a  locality  where  the  air  is  pure 
and  salubrious — never,  if  it  can  be  avoided,  in  the  wards  of  a  crowded 
hospital,  and  if  a  choice  be  offered,  in  the  country  rather  than  the  city. 
The  day  selected  should  be  clear,  and  neither  very  hot  nor  very  cold.  If 
the  weather  be  cool,  the  temperature  of  the  apartment  should  be  kept  at 
from  seventy-eight  to  eighty  degrees.  A  thoroughly  experienced  nurse 
should  be  in  readiness  to  take  charge  of  the  patient. 

After  the  operation  it  is  essential  that  the  bowels  should  be  kept  con- 
stipated for  a  week  or  ten  days.  That  this  may  be  done  without  inconve- 
nience they  should  be  empty  at  the  time  of  operation.  To  effect  this, 
during  the  week  preceding  it  they  should  be  acted  upon  by  a  gentle  laxa- 
tive every  second  day,  and  the  patient  kept  for  two  days  previous  to  the 
operation  upon  animal  broths,  beef-tea,  milk,  and  gruels  like  those  of  farina 
or  Indian  meal. 

Five  hours  before  operation  I  am  in  the  habit  of  giving  from  twelve  to 
fifteen  grains  of  quinine  with  a  quarter  of  a  grain  of  morphia.  The  skin 
should  be  put  into  good  condition  by  warm  baths  employed  daily  for  a  week 
or  more,  and  its  temperature  kept  equable  during  the  operation  by  a  flannel 
wrapper  and  drawers.  As  the  time  for  operation  arrives,  the  bladder  should 
be  carefully  evacuated,  the  patient  anaesthetized,  and  laid  upon  her  back 
upon  a  table,  of  suitable  height  and  strength,  which  is  covered  by  folded 
counterpanes  or  blankets,  and  placed  before  a  window  affording  a  good 
light. 

What  the  verdict  of  the  future  will  be  i;i  reference  to  the  full  applica- 
tion of  the  antiseptic  method  to  ovariotomy,  no  one  can  now  say.  It  is 
very  possible  that  the  use  of  the  spray  may  be  discarded  ;  it  is  highly  pro- 
bable that  all  the  other  steps  of  the  procedure  which  so  surely  secure  per- 
fect cleanliness  and  prevent  contamination  by  disease-germs  will  live  as 


734  OVARIOTOMY. 

long  as  surgery  does.  "With  our  present  lights,  however,  no  man  is  justified 
in  casting  aside  a  method  which  promises  so  much  of  security,  and  has 
already  produced  such  excellent  results.  Everything  should  therefore  be 
prepared  for  full  practice  of  the  Listerian  plan. 

The  operator  will  require  five  assistants,  one  to  administer  the  anaesthetic 
one  to  stand  opposite  to  him  and  aid  in  manipulating  the  tumor  and  abdo- 
minal wall,  one  to  take  charge  of  the  instruments,  one  to  apply  ligatures 
the  actual  cautery,  etc.,  and  a  fifth  to  take  charge  of  the  atomizer.     The 
nurse  who  is  to  take  charge  of  the  patient  may  look  after  the  cleansing 
and  supply  of  clean  sponges  wrung  out  of  carbolized  water. 

The  Operation — Although  this  operation  has  of  late  years  been  so  fully 
discussed  and  so  free  an  interchange  of  sentiment  concerning  it  has  been 
afforded,  there  is  not  one  point  connected  with  it  upon  which  operators  are 
agreed.  The  extent  of  incision,  management  of  pedicle,  closure  of  wound, 
and  the  other  steps  which  will  be  alluded  to,  are  still  subjects  upon  which 
great  variety  of  opinion  exists.  I  shall  avoid  discussion,  and  hoping  to  be 
pardoned  for  any  appearance  of  dogmatism  which  may  result  from  so  doin», 
give  such  a  description  as  will,  according  to  my  view,  best  meet  the  re- 
quirements of  practice. 

The  steps  of  the  operation  are  these  : — 

1st.  Incision  through  abdominal  walls  ; 

2d.  Tapping  tumor ; 

3d.  Removal  of  the  sac  ; 

4th.  Securing  the  pedicle  ; 

5th.  Cleansing  the  peritoneum ; 

6th.  Establishing  drainage,  if  necessary ; 

7th.  Closing  abdominal  wound  ; 

8th.  Applying  antiseptic  dressing. 
T7ie  incision  is  made  by  a  bistoury  held  by  the  operator,  who  stands  at 
the  right  side  of  the  patient.  It  should  pass  directly  through  the  linea 
alba,  and  should  extend  from  a  point  at  a  varying  distance  below  the  navel 
to  one  a  little  above  the  symphysis  pubis.  Passing  through  the  skin  and 
adipose  tissue,  layer  by  layer,  it  is  continued  until  the  operator  sees  the 
fibrous  sheath  of  the  recti  muscles.  An  inexperienced  operator  may  take 
this  for  the  peritoneum.  If  any  doubt  exist,  it  should  not  be  incised  until 
exposure  to  the  air  and  pressure  by  forceps,  fingers,  or  sponges,  have 
cheeked  the  venous  flow  occurring  from  the  vessels  exposed  by  the  abdo- 
minal incision.  Then  the  fibrous  structure  should  be  caught  by  a  tenacu- 
lum, snipped  with  scissors,  and  a  grooved  director  passed  under  it,  upon 
which  it  may  be  slit.  If  this  expose  the  belly  of  one  of  the  recti,  it  will 
be  evident  that  the  linea  alba  has  not  been  struck  by  the  incision.  To 
reach  it,  the  director  should  be  pushed  under  the  sheath  across  the  muscle, 
and  it  will  be  arrested  at  the  linea,  where  the  incision  should  be  made. 
All  hemorrhage  having  ceased,  the  parietal  peritoneum  should  be  lifted  by 


TUB    OPERATION.  735 

the  tenaculum,  snipped,  and  slit  upon  the  director  for  the  length  of  the 
incision. 

During  this  part  of  the  operation  small  vessels  may  pour  forth  hlood 
quite  freely.  It  is  not  necessary  to  ligate  them,  temporary  compression 
hy  hemostatic  forceps  usually  controlling  their  flow  perfectly. 

It  may  be  supposed  that  no  difficulty  could  arise  in  cutting  through  the 
abdominal  walls,  but  this  is  not  so.  Operators  will  sometimes  commit 
most  serious  errors  even  here.  In  two  cases,  one  of  which  occurred  to 
myself,  and  the  other  to  a  very  skilful  operator  of  this  city,  the  incision 
was  carried  only  down  to  the  parietal  peritoneum,  when  this  was  stripped 
away  from  the  muscles  under  the  impression  that  it  was  an  attached  cyst 
wall.  In  other  cases  operators  have  become  confused  in  searching  for  the 
linea  alba,  and,  in  others  still,  the  incision  which  should  open  only  the 
abdomen  lays  open  the  cyst  itself,  and  allows  its  contents  to  flow  away 
prematurely.  By  cutting  at  first  only  through  skin  and  areolar  tissue, 
and  then  applying  the  tenaculum  to  all  doubtful  tissues,  these  difficulties 
may  be  to  a  great  extent  avoided.  It  is  hazardous  to  open  the  peritoneum 
by  the  knife,  and  always  wise  to  lift  it  by  the  tenaculum,  snip  it  with 
scissors,  and  slit  it  up  upon  a  director.  Sometimes  a  loop  of  intestine 
may  be  found  over  the  anterior  face  of  the  tumor,  as  happened  in  one  of 
Mr.  Baker  Brown's  cases,  where  it  would  have  been  incised  had  the 
operator  not  slit  the  peritoneum  upon  a  director  with  scissors.  In  one 
case,  published  by  Dr.  McLane,  of  Troy,  the  bladder  lay  over  the  tumor, 
and  was  drawn  up  towards  the  umbilicus  so  far  that  both  its  walls  were 
cut  through  by  the  abdominal  section. 

As  a  rule,  the  shorter  the  abdominal  incision  the  better  for  the  after 
progress  of  the  case. 

Mr.  Brown  has  laid  down,  in  reference  to  the  abdominal  section,  this 
important  rule :  it  should  always  be  regarded  originally  as  an  explorative 
incision.  If  any  condition  contraindicating  the  removal  of  the  sac  be 
found  to  exist,  it  may  then  be  closed  without  exposure  of  the  patient  to 
great  danger,  while,  if  it  be  found  advisable  to  enlarge  it  to  proceed,  this 
may  be  done  to  any  necessary  extent.  Mr.  Wells  has  removed  one  sac 
by  an  incision  of  one.  inch  and  a  half,  and  rarely  resorts  to  one  of  over 
five  inches.  On  the  other  hand,  Dr.  Clay,  whose  favorable  statistics 
have  been  alluded  to,  prefers  the  long  incision.  The  great  dread  which 
has  always  been  entertained  of  cutting  into  and  exposing  the  peritoneum, 
lends  a  degree  of  fascination  to  the  short  incision.  But  when  it  is  borne  in 
mind  that,  for  want  of  a  sufficiently  free  incision,  a  tumor  is  often  slowly 
and  clumsily  removed,  bleeding  vessels  not  detached,  and  an  unclean  peri- 
toneum closed  up  in  place  of  a  clean  one,  it  will  be  recognized  that  an 
operator  may  err  in  this  direction  as  well  as  in  the  other. 

The  results  of  Mr.  Wells,  as  embodied  in  the  following  table,  prove, 
however,  that  short  incisions  are  greatly  to  be  preferred  to  long  ones. 


736  OVARIOTOMY. 

No.  of  cases.     Recoveries.     Deaths.     Mortality. 
Not  exceeding  G  in.,  440  337  103  23.4  per  cent. 

Exceeding  6  in.,  60  36  24  40.       "      " 

It  is  equally  worthy  of  note  that  the  same  surgeon  operated  on  17  cases 
by  an  incision  of  3  inches,  and  lost  23.53  per  cent.,  and  on  203  cases  by 
an  incision  of  5  inches,  and  lost  l'J.7  per  cent. 

The  most  rational  deduction  to  be  drawn  from  these  facts  is  this :  that 
the  shorter  the  incision  by  which  the  sac  can  be  removed  "  tuto,  cito,  et 
jucunde,"  the  better  for  prognosis.  The  effort  to  remove  the  sac,  how- 
ever, through  an  opening  so  small  as  to  involve  delay,  uncertainty,  and 
inefficient  manipulation  gives  the  patient  a  poorer  prospect  for  recovery 
than  the  making  of  a  longer  incision  would  offer. 

The  shining  wall  of  the  cyst,  covered  by  visceral  peritoneum,  being 
now  under  the  fingers  and  eyes  of  the  operator,  lie  has  an  opportunity  of 
verifying  his  diagnosis  by  palpation,  visual  examination,  and  removal  of 
fluid  by  a  very  small  trocar  and  canula  or  by  the  needle  of  the  hypodermic 
syringe.  Should  connection  with  the  uterus  be  suspected,  before  pro- 
ceeding further  its  relations  to  this  organ  should  be  determined  by  passing 
the  uterine  sound,  and  rotating  the  uterus  while  two  fingers  are  passed 
through  the  abdominal  wound  down  to  the  fundus  uteri. 

Before  this,  however,  the  operator  may  be  checked  in  his  progress  by 
discovering  that  he  is  not  in  contact  with  the  cyst  wall,  although  the  perito- 
neum be  opened.  In  place  of  the  smooth,  shining  wall  of  the  cyst,  he 
discovers  a  vascular  membrane  containing  large  vessels,  which  spreads 
over  the  tumor  like  an  apron.  To  one  who  has  never  seen  this  covering 
it  will  prove  very  perplexing.  It  consists  of  the  peritoneal  walls  or  roof 
of  the  broad  ligaments  which  have  been  spread  out  by  the  growing  tumor 
and  have  undergone  great  hypertrophy.  Tumors  thus  surrounded  have, 
according  to  my  experience,  broad  and  short  pedicles,  and  their  extir- 
pation will  be  very  difficult  unless  the  valuable  method  advised  by  Dr. 
Miner,  of  Buffalo,  be  adopted.  It  consists  in  cutting  through  the  envelope 
of  the  cyst,  avoiding,  as  far  as  possible,  the  opening  of  large  vessels,  in- 
troducing the  fingers,  and  enucleating  the  tumor.1  The  sac  which  is  left 
should  then  be  opened,  thoroughly  cleansed,  touched  all  over  its  oozing 
surface  with  solution  of  persulphate  of  iron,  and,  if  large,  tied  around  a 
drainage  tube. 

Should  any  doubt  exist  in  the  mind  of  the  operator  whether  the  struc- 
ture which  he  sees  through  the  incision  is  really  the  cyst  wall  or  the  peri- 
toneum covering  it,  he  may  endeavor  to  pass  a  finger  thoroughly  washed  in 

1  I  have  resorted  to  this  method  a  great  many  times,  with  good  results,  in  cases 
which  would  have  proved  unmanageable  by  other  means.  It  appears  to  me  to  be 
one  of  the  most  valuable  of  all  the  contributions  to  ovariotomy  which  have  ema- 
nated from  this  country. 


TAPPING.  737 

carbolized  water  between  the  cyst  and  peritoneum,  or  a  steel  sound  may  be 
gently  swept  around  if  it  be  possible. 

Tapping Before  tapping  it  is  my  habit  to  turn  the  patient  on  the  side 

towards  the  operator,  whose  special  attention  at  this  moment  should  be 
directed  to  two  objects — one  preventing  the  eseape  of  even  one  drop  of  fluid 
into  the  peritoneal  cavity,  the  other  the  avoidance,  as  far  as  possible,  of  the 
introduction  of  his  hands  or  fingers  into  it.  Turning  the  patient  on  the 
side  greatly  facilitates  the  second  of  these,  and  by  no  means  increases  the 
difficulties  of  the  first.  The  assistant  opposite  the  operator,  now  stand- 
ing at  the  back  of  the  patient,  steadies  her  body  with  his  right  hand, 
while  with  his  left  he  presses  a  soft,  carbolized  towel,  or  sponge,  firmly 
against  the  abdominal  wall  just  below  the  incision,  so  as  to  prevent  in- 
gress of  fluid  to  the  peritoneal  cavity.  The  operator  should  now  thoroughly 
cover  the  raw  lips  of  the  wound  with  carbolized  vaseline,  or  some  other 
unctuous  substance,  to  prevent  absorption  of  the  colloid,  perhaps  the  de- 
composing, purulent  fluid,  of  the  sac,  which  is  now  to  be  tapped  and 
withdrawn. 

With  a  long  curved  trocar  and  canula,  such  as  that  shown  in  Fig.  2.">7, 
the  fluid  of  the  sac  is  now  allowed  to  flow  away  if  it  be  not  too  tenacious 
to  do  so. 

Fig.  257. 


Emmpfs  trocar  and  canula  for  tapping  cysts. 

I  have  cast  aside  entirely,  and  would  advise  others  to  do  so,  the  cum- 
brous attachments  to  trocars  intended  to  carry  off*  the  fluid  of  the  sac 
without  soiling  the  surroundings  of  the  patient.  If  a  large  wash-tub  be 
placed  upon  the  floor,  and  a  little  skill  and  care  be  displayed  by  the  ope- 
rator, no  necessity  for  them  will  be  found  to  exist.  / 

Let  us  suppose  that  the  sac  contents  flow  away  easily  and  freely;  the 

operator  should  wait  until  the  visible  portion  of  the  sac  protrudes  a  little 

through  the  abdominal  opening;  then  he  should  fix  a  tenaculum  in  it  and 

draw  the  opening  in  which  rests   the  canula,  just  beyond  the  abdominal 

47 


738  OVARIOTOMY. 

wound.  In  a  few  minutes  a  second  tenaculum  should  be  fixed  in  the  sac, 
and  very  soon  it  will  protrude  decidedly.  As  soon  as  it  is  outside  the 
abdomen,  the  canula  may  be  with  advantage  withdrawn,  and  a  free  open- 
ing made  into  the  sac  by  a  pair  of  scissors,  to  prevent  the  waste  of  time 
which  would  attend  its  slow  evacuation  through  the  canula. 

If  one  sac  be  emptied  and  another  be  felt,  the  operator  may  introduce 
the  trocar  into  the  canula,  turn  this  obliquely,  and  plunge  it  into  the 
remaining  cyst  or  cysts ;  or  he  may,  and  this  is  usually  safer  and  better, 
pass  one  or  two  fingers,  or  the  entire  hand,  into  the  main  sac  and  rupture 
the  remaining  ones  in  this  way  and  allow  their  contents  to  flow  out.  In 
doing  this  the  hand  should  never  be  passed  into  the  peritoneal  cavity,  and 
great  care  should  be  observed  not  to  break  any  remaining  cyst  so  as  to 
let  it  communicate  with  that  cavity.  This  manoeuvre  is  a  very  important 
and  effectual  one,  and  withal  a  very  safe  one,  since  the  cyst  walls  protect 
the  peritoneal  cavity  thoroughly.  It  is  far  safer  than  the  plan  of  plunging 
a  trocar  and  canula  blindly  about  in  search  of  cysts,  and  than  that  of 
passing  the  hand  into  the  peritoneum  to  find  them. 

While  the  fluid  is  pouring  out,  compression  of  the  abdominal  walls 
against  the  tumor  should  be  made  by  an  assistant,  who  places  one  hand 
on  each  side  of  the  abdominal  incision,  and  the  sac  should  be  kept  from 
slipping  into  the  abdomen  by  strong  forceps  made  to  grasp  its  lips,  if  an 
ordinary  canula  be  employed. 

Suppose,  however,  that  the  fluid  of  the  cyst  is  semi-solid  colloid,  that 
numerous  very  small  cysts  exist,  or  that  a  large  amount  of  solid  material 
prevents  evacuation  of  the  tumor  by  trocar ;  what  then  is  to  be  done? 
Passing  two  large  and  strong  tenacula  into  the  tumor  at  the  extreme  upper 
and  lower  extremities  of  the  abdominal  wound,  and  holding  it  firmly 
against  it,  the  surface  of  the  tumor  between  these  tenacula  should  be  cut 
through,  and  one  finger,  then  two,  and  then  the  whole  hand  introduced, 
breaking  up  as  it  goes  little  cysts,  and  at  once  evacuating  their  contents. 
When  the  hand  has  well  entered  the  tumor,  a  species  of  "conjoined 
manipulation,"  one  hand  on  the  abdomen  and  the  other  in  the  tumor,  will 
serve  to  reveal  the  presence  of  all  cysts  not  yet  evacuated. 

In  this  way  immense  tumors  may  be  delivered  without  introducing  the 
hand  into  the  peritoneal  cavity,  without  making  a  long  abdominal  incision, 
and  without  allowing  the  escape  of  sac  contents  within  the  abdomen. 

Removal  of  the  Sac The  sac,  being  now  drawn   out  by  the   tooth 

forceps,  tenacula,  or  pincers,  which  have  been  fixed  in  it  to  prevent  its 
escape  into  the  abdomen,  is  seized  by  the  fingers  of  the  operator  and 
gently  drawn  forth  through  the  incision.  This  is  the  time  for  breaking 
adhesions,  and  this  is  best  done,  as  a  rule,  by  steady  traction  upon  the 
sac.  In  the  large  majority  of  cases  traction,  steady  and  even  powerful 
traction,  upon  the  sac  is  the  best,  most  rapid,  and  safest  method  of  severing 
attachments.     Of  course,  this  must  not  be  rash  or  intemperate  in  degree, 


REMOVAL    OF    THE    SAC.  780 

for  by  that  serious  damage  might  be  done ;  but  it  should  be  bo  firm  and 
decided  as  to  break  all  ordinary  attachments. 

If  an  adhesion  which  resists  the  efforts  thus  made  to  rupture  the  attach- 
ments hold  the  sac  in  the  abdomen,  this  should  be  fully  exposed,  and 
severed  by  detaching  it  from  the  cyst  wall  by  the  fingers,  which  will  now 
reach  it  readily  ;  by  the  actual  cautery,  as  suggested  by  Mr.  Drown,  if  it 
be  long  enough  to  avoid  cauterization  of  the  abdominal  wall ;  by  scissors, 
if  a  cutting  instrument  must  be  used  ;  or  by  a  small  eeraseur,  if  it  can  be 
applied.  No  rule  can  be  given  as  to  the  best  method,  for  each  case  will 
require  the  plan  specially  adapted  to  its  peculiar  features.  This  maxim 
must  be  constantly  borne  in  mind — that  plan  is  best  which  severs  attach- 
ments without  injuring  viscera  or  leaving  bloodvessels  open,  for  these  are 
the  two  evils  to  be  feared.  If  a  flow  of  blood  follow  the  severance  of  an 
adhesion,  the  bleeding  vessel  should  be  exposed  and  ligated  or  touched 
with  the  actual  cautery  so  lightly  as  not  to  create  a  slough. 

By  the  means  recommended,  adhesions  may  generally  be  severed  with- 
out the  application  of  ligatures,  but  now  and  then  this  is  necessary.  If  it 
be  so,  silk  should  be  unhesitatingly  employed  as  a  method  of  ligation. 
Metallic  ligatures  are  unwieldy  and  unreliable,  and  none  of  the  other  ani- 
mal ligatures  compare  favorably  with  silk.  In  some  cases  the  cyst  adheres 
so  strongly  to  some  viscus  that  it  cannot  be  separated.  Under  these  cir- 
cumstances a  portion  of  the  cyst  wall  should  be  cut  out  and  allowed  to 
remain  upon  the  surface  to  which  it  so  pertinaciously  clings.  M.  Boinet 
points  out  the  propriety  of  removing  the  secreting  surface  of  such  a  piece 
before  leaving  it. 

Sometimes  instead  of  adhesions  here  and  there  the  cyst  is  found  uni- 
versally attached  over  the  pelvis,  and  the  operator  sees  cause  to  fear  lest 
the  removal  of  the  whole  cyst  may  prove  impracticable.  This  condition 
of  things  may  be  dealt  with  in  one  of  two  ways.  The  operator  may  strip 
the  envelopes  of  the  sac  away  from  it  about  three  inches  above  the  attached 
surface  and  enucleate  its  lower  segment  ;  or  if  he  find  this  impossible,  or 
deem  it  to  be  very  hazardous  on  account  of  hemorrhage,  he  may  pass 
into  the  extremity  of  the  sac  a  glass  drainage  tube,  tie  the  sac  firmly 
around  this,  and  fixing  both  sac  and  tube  between  the  lips  of  the  abdomi- 
nal wound  drain  it  and  inject  with  carbolized  fluid. 

There  are  little  manoeuvres  which  experience  will  teach  the  operator 
which  will  greatly  assist  in  removal  of  the  sac  from  the  abdomen  when 
difficulties  present  themselves.  One  of  these,  which  I  learned  of  Mr. 
Spencer  'Wells,  consists  in  ignoring  the  attachments  at  the  upper  part  of 
the  sac,  seizing  its  lowest,  inner  portion,  pulling  this  out  through  its  mouth, 
and  thus  completely  inverting  it.  Another  consists  in  ligating  the  tumor, 
when  much  solid  matter  exists  at  its  lower  extremity,  before  complete 
emptying  of  it,  turning  it  over,  and  delivering  the  pelvic  extremity  first. 
A  third  plan  is  applicable  when  the  upper  portion  of  the  tumor  is  fluid, 


740 


OVARIOTOMY. 


and  that  below  the  umbilicus  solid,  and  consists  in  passing  the  long  trocar 
through  the  solid  portion  obliquely  upwards,  emptying  the  upper  sac,  pull- 
ing this  down  and  out  first,  and  then  dragging  out  the  solid  portion  near 
the  pelvis.  By  adopting  these  methods  in  suitable  cases,  it  is  surprising 
to  see  through  how  short  an  incision  a  colossal  and  semi-solid  tumor 
may  be  extracted.  Very  recently  I  removed  one  in  the  Woman's 
Hospital  weighing  over  sixty  pounds,  through  an  opening  of  less  than  five 
inches. 

The  tumor  being  freed  from  attachments  is  now  drawn  forth,  and  the 
pedicle  seized  in  the  fingers.  At  this  point  there  is  usually  a  delay  caused 
by  the  time  required  by  the  operator  for  determination  as  to  the  plan 
which  will  be  best  adapted  to  securing  the  pedicle.  There  is  often,  too, 
some  discussion  upon  this  point,  for  no  operator  should  be  wedded  to  any 
single  plan  which  he  adopts  in  all  cases.     If  the  sac  be  left  attached  to 

Fig.  258. 


Dawson's  temporary  clamp. 


the  pedicle  during  this  time,  it  is  greatly  in  the  way,  drags  heavily,  soils 
the  clothing,  and  usually  forces  entrance  of  its  contents  into  the  abdomen. 
I  have  been  in  the  habit  of  rapidly  encircling  the  mass  some  inches  from 
the  pedicle  with  a  strong  ligature,  cutting  off  the  sac,  and  then  at  leisure 
examining  the  pedicle.  Dr.  B.  F.  Dawson  has  devised  for  this  purpose 
the  temporary  clamp  shown  in  Fig.  258.  By  this  the  vessels  of  the 
pedicle  are  secured,  and  this  part  compressed  circularly  instead  of  later- 
ally, while  it  is  secured  by  the  means  which  are  to  be  permanent. 

Securing  the  Pedicle. — This,  which  constitutes  one  of  the  most  import- 
ant steps  of  the  operation,  is  at  times  easily  and  satisfactorily  accomplished, 
while  at  others  it  is  invested  with  great  difficulties.  Unless  the  pedicle  be 
excessively  short,  the  sac  may  be  drawn  outside  of  the  abdomen  and  its 
pedicle  grasped  by  the  fingers.     When  very  short  it   has  to  be  manipu- 


SECURING    THE    PEDICLE. 


741 


lated  in  the  abdomen.  It  may  be  managed  after  one  of  the  following 
methods,  that  one  being  selected  which  best  meets  the  requirements  of  the 
particular  ease. 

1st.  The  pedicle  may  be  constricted  by  a  clamp  and  held  outside  of  the 
abdominal  cavity. 

2d.  The  pedicle  may  be  securely  ligated  and  held  between  the  lips  of 
the  wound  by  pins  or  sutures. 

3d.  The  pedicle  may  be  transfixed  by  double  ligatures,  which  being  cut 
short,  it  is  dropped  into  the  pelvic  cavity. 

4th.  The  tumor  may  be  enucleated. 

5th.  The  pedicle  may  be  constricted  by  a  temporary  clamp  and  severed 
by  the  actual  cautery. 

A  large  number  of  other  methods  have  been  advised  and  practised,  and 
to  those  interested  in  the  matter,  I  would  recommend  the  work  of  Dr. 
Peaslee  on  Ovarian  Tumors  where  they  are  considered  at  length.  I  men- 
tion here  only  those  which  appear  to  me  deserving  of  special  consideration 
and  unquestionable  reliance. 

Fig.  259. 


Thomas's  clamp. 


The  prevention  of  hemorrhage  by  the  ligature  and  clamp  is  evidently 
identical  in  principle.  The  clamp,  however,  has  the  advantage  of  being 
simpler  and  more  easily  applied.  The  clamp  shown  in  Fig.  259  is  that 
which  I  invariably  employ.  It  appears  to  me  to  present  all  the  advan- 
tages and  few  of  the  evils  which  attach  to  others. 

It  is  thus  employed:  the  pedicle  or  neck  of  the  tumor  being  held  in  the 
fingers  ;  the  clamp,  Fig.  259,  is  adjusted  so  that  one  limb  passes  over  one, 
and  the  other  over  the  other  side  of  it ;  the  two  branches  are  then  closely 
approximated  so  as  to  obliterate  the  vessels,  and  the  sac  is  amputated 
above  this  by  a  bistoury.  The  clamp  is  then  laid  flat  upon  the  abdomen' 
and  the  incision  closed. 

When  the  ligature  is  employed  in  the  extra-peritoneal  method,  the  sac 


742  OVARIOTOMY. 

is  amputated  and  the  stump  placed  between  the  lips  of  the  wound  and 
transfixed  by  large  pins,  or  the  sutures  which  close  this  part  of  the 
incision. 

Dr.  Tyler  Smith  was  instrumental  in  rendering  popular  a  method  which 
was  practised,  according  to  Dr.  Peaslee,  as  long  ago  as  1829,  by  Dr. 
Rogers,  and  afterwards  by  Dr.  Billington,  of  this  city.  It  consists  in 
ligating  the  stump,  cutting  both  ligature  and  pedicle  as  short  as  possible, 
returning  them  to  the  abdomen,  and  closing  the  abdominal  incision.  A 
great  deal  of  prejudice  has  existed  against  this  return  of  the  pedicle.  By 
theoretical  reasoning  it  is  true  that  the  practice  can  be  made  to  appear  very 
objectionable,  but  it  is  not  theory  which  should  decide  us  in  reference  to 
so  grave  a  matter ;  the  results  of  practice  should  outweigh  all  theory, 
and  no  one  should  yield  aught  to  mere  feeling.  This  unwarrantable  preju- 
dice against  the  leaving  of  silk  in  the  peritoneum,  for  so  I  regard  it,  has 
been  strengthened  by  the  report  of  3-4  cases  of  ovariotomy  by  Spencer 
Wells;  of  these,  4  were  treated  by  return  of  ligature  to  the  abdomen,  and 
all  died ;  30  were  treated  by  clamp,  and  all  recovered.  Peaslee,  whose 
statistics  were  17  recoveries  out  of  26  operations;  Tyler  Smith,  who 
reported  14  successes  in  17  operations;  and  Bradford,  who  saved  28 
out  of  31  cases,  all  employed  this  plan  universally.  I  confess  that  I  once 
shared  in  the  prejudice  to  which  I  have  made  allusion,  but  experience  has 
caused  me  to  change  my  mind  with  regard  to  it.  In  1878  Mr.  Knowsley 
Thornton,  of  London,  whose  success  as  an  ovariotomist  entitles  his  opinion 
to  great  weight,  reported  very  strongly  in  favor  of  the  silk  ligature  and 
return  of  the  pedicle. 

An  objection  to  the  use  of  the  ligature  cut  short  and  returned  to  the 
peritoneal  cavity  which  has  been  raised  upon  theoretical  grounds  is,  that 
gangrene  of  the  portion  of  the  stump  distal  to  the  ligature  was  likely  to 
occur,  and  prove  a  source  of  septicaemia.  Spiegelberg  and  Waldeyer  have, 
however,  proved  that  after  the  application  of  a  ligature  upon  the  horns  of 
the  uterus  the  portions  of  tissue  distal  to  them  do  not  become  gangrenous, 
but  are  encapsulated  by  effused  lymph. 

Koeberle,  of  Strasbourg,  employed  the  clamp  when  the  pedicle  was  long  ; 
but  when  short,  he  compressed  the  stump  by  a  species  of  constrictor  which 
tightens  a  metallic  wire  that  surrounds  the  pedicle. 

Enucleation  will  never  prove  applicable  to  a  large  number  of  cases,  for 
where  a  pedicle  can  be  treated  by  any  of  the  methods  thus  far  mentioned, 
it  will  offer  no  advantages.  Where,  however,  there  is  no  pedicle,  it  pre- 
sents itself  as  a  most  valuable  resource,  and  comes  into  use  in  a  class  of 
cases  to  which  no  other  plan  is  applicable. 

The  most  remarkable  results  have  attended  the  use  of  the  actual 
cautery  in  the  treatment  of  the  pedicle,  combined  with  the  antiseptic 
method  in  the  hands  of  Mr.  Thomas  Keith,  of  Edinburgh.  Out  of  his 
last  seventy  ovariotomies,  he  has  not  had  a  death ! 


SECURING    THE    PEDICLE. 


743 


No  rule  can  be  given  with  reference  to  a  choice  between  all  these 
methods  other  than  this:  when  the  pedicle  is  long  and  slender,  it  does  not 
appear  to  matter  very  much  which  plan  is  selected,  for  all  have  yielded 
and  are  daily  yielding  excellent  results  ;  but  when  it  is  very  short,  the 
external  does  not  promise  nearly  so  well  as  the  internal  method  of  man- 
aging the  stump. 


Fiu.  2G0. 


Storer's  clamp-shield. 


As  to  the  special  cases  for  applying  the  different  plans,  the  following 
suggestions,  not  rules,  may  be  of  service  : — 

a.  The  clamp  is  applicable  to  long  pedicles,  requiring  powerful  ligation, 
and  presenting  a  large  amount  of  tissue  for  suppuration  and  decay. 

b.  Ligation  and  return  is  applicable  to  tumors  with  pedicles  too  short 
for  treatment  by  the  clamp,  and  to  slender  pedicles. 

c.  Enucleation  gives  a  method  of  removal  of  tumors  which  have  no 
pedicles. 

d.  Since  the  experience  of  Mr.  Keith,  the  use  of  the  actual  cautery 
should  be  again  fully  tried,  for  its  utility  may  now  be  considered  beyond 
question.  Where  it  is  employed  deep  in  the  pelvis,  Storer's  clamp-shield, 
Fig.  260,  is  an  excellent  adjuvant  for  prevention  of  hemorrhage  during  its 
use,  and  a  good  protection  to  the  surrounding  parts. 

The  statement  just  made  as  to  its  being  immaterial  whether  the  pedicle 


744 


OVARIOTOMY, 


is  returned  or  not,  in  ordinary  cases,  is  based  upon  the  comparative  results 
of  those  who  do  not  return  it,  with  those  of  other  operators  who  do. 

The  following  analysis  of  a  large  number  of  cases  is  given  with  reference 
to  this  point  by  Dr.  J.  Clay  : — 


Class  of  cases. 

c-i  »   j  i  *S   Inferred 
Stated  left  left  with. 

within  the      iuthe 

abdomen,  j  abdomen. 

Kept          Tied  in 
without         two  or 
by  various  |      more 
methods.  |  portions. 

i 

8imply 
ligatured. 

Stitched 

In 
wound. 

Ecraseur 
used  to 
divide  it. 

Successful .   . 
Unsuccessful 

113 

58 

76 
97 

20 

25 

122 

57 

22 
26 

3 
3 

2 
1 

Total    .  .  . 

171 

173 

45            179 

48 

6 

3 

Upon  theoretical  grounds  it  would  appear  that  parturition  in  the  future 
would  be  much  less  unfavorably  affected  after  the  performance  of  ovari- 
otomy with  return  of  the  pedicle  to  the  abdominal  cavity  than  after  the 
same  operation,  the  clamp  being  employed.  Statistical  evidence  upon  the 
subject  is  wanting.  Dr.  Walter  F.  Atlee1  relates  a  case  where  death  oc- 
curred to  mother  and  child  from  powerless  labor,  of  which  he  says  : — 

"  I  think  myself  that  the  difficulty  in  this  case  arose  from  the  irregularity 
of  the  contractions  in  a  deformed  womb.  The  left  horn  being  fast  to  the 
abdominal  wall  at  the  lower  end  of  the  old  cicatrix,  which  was  just  above 
the  pubis,  the  womb,  as  it  developed  around  the  child,  must  have  done  so 
in  a  very  different  way  from  what  occurs  in  ordinary  cases.  As  it  is,  I 
have  thought  it  well  to  report  the  case  as  bearing  upon  the  question  of  the 
proper  mode  of  securing  the  pedicle,  when  very  short,  in  ovariotomy." 

Before  proceeding  to  the  next  step  of  the  operation,  the  remaining  ovary 
should  always  be  carefully  examined  as  to  the  existence  of  disease.  Upon 
the  removal  of  a  large  ovarian  cyst,  it  is  very  common  to  find  very  small 
cysts  disseminated  throughout  the  other  ovary.  If  any  of  these  have  ob- 
tained considerable  size,  it  is  advisable  that  this  should  be  removed. 
But  if  they  be  too  small  to  call  for  this  course,  the  matter  may  be  compro- 
mised by  puncture  of  them  with  a  needle.  Pippingskoeld,2  of  Helsingford, 
Finland,  advises  that  the  small  cysts  should  be  punctured  and  their  walls 
rapidly  but  efficiently  cauterized  with  a  pointed  actual  cautery.  He  de- 
clares that  he  has  resorted  to  this  plan  in  many  cases  and  with  uniformly 
good  results. 

Cleansing  the  Peritoneum The  sac  having  been  removed  and  hemor- 
rhage checked,  all  fluids  contained  in  the  peritoneal  cavity  should  be  care- 
fully removed  by  soft  sjKmges  squeezed  out  of  warm,  carbolized  water. 
Not  only  the  intestines  and  abdominal  walls,  but  especially  the  pelvis, 
should  be  completely  and  thoroughly  cleansed.     This  is  a  point  of  great 


«  Amcr.  Journ.  Med.  Sri.,  April,  1880,  p.  394. 
>  Am.  Journ.  Obstetrics,  April,  1880. 


ESTABLISHING    DRAINAGE.  745 

importance,  and  may  decide  the  issue  of  the  case.  Every  particle  of  fluid 
left  may  undergo  decomposition,  and  expose  to  the  great  dangers  of  septi- 
caemia and  peritonitis. 

Establishing  Drainage No  one  familiar  with  ovariotomy  will  to-day 

doubt  the  assertion  that  the  two  factors  which  prove  most  fatal  after  it, 
septicaemia  and  peritonitis,  are  both  in  great  degree  due  to  the  retention  of 
putrescent  materials  within  the  peritoneal  cavity.  These  materials  may 
have  escaped  from  the  cyst  during  or  before  the  operation,  may  consist  of 
blood  or  serum  oozing  from  vessels  while  the  operation  proceeds,  or  some 
hours  after  it  has  ended,  or  arise  from  emptying  of  pus  into  the  peritoneum 
from  inflammatory  action.  The  importance  of  not  only  preventing  the 
entrance  of  such  elements  into  the  peritoneum,  and  of  removing  them  be- 
fore closing  the  abdominal  opening,  but  also  of  giving  them  free  vent 
during  the  period  of  convalescence  has  attracted  the  attention  of  many 
ovariotomists.  Peaslee  introduced  the  plan  of  leaving  a  cloth  tent  in  the 
lower  angle  of  the  wound  in  order  to  facilitate  drainage  in  case  of  the  de- 
velopment of  septicaemia.  Koeberle  not  only  inserted  channels  of  metal 
through  the  abdomen,  but  even  opened  through  the  cul-de-sac  of  Douglas 
and  inserted  tubes,  so  as  to  drain  per  vagi  nam,  and  Sims  more  recently 
has  urged  this  plan  as  one  very  greatly  calculated  to  diminish  the  liability 
to  these  conditions. 

The  removal  of  the  cloth  tertt,  fixed  between  the  lips  of  the  wound  by 
congealed  blood,  is  often  difficult  and  painful,  and  the  passage  of  a  catheter 
or  other  tube  down  into  Douglas's  sac,  the  most  dependent  part  of  the 
peritoneum,  is  not  rarely  impossible  after  a  slight  effusion  of  lymph  has 
occurred. 

Drainage  per  vaginam  by  means  of  tubes  passed  up  into  the  peritoneum 
is,  I  think,  calculated  to  increase  the  dangers  of  ovariotomy,  by  opening  a 
way  for  putrid  fluids  from  the  peritoneum  into  the  pelvic  cellular  tissue. 
I  have  practised  it  twice  and  seen  it  adopted  many  times,  and  it  is  upon 
the  evil  results  thus  far  observed  at  the  bedside  that  I  base  my  estimate  of 
its  value. 

For  the  past  fifteen  years,  whenever,  from  the  remaining  of  a  portion  of 
the  sac  in  the  pelvis,  or  from  escape  of  fluids  into  the  pelvic  peritoneum, 
drainage  has  seemed  advisable,  I  have,  until  recently,  employed  for  this 
purpose  a  curved  glass  tube,  which  entered  and  rested  in  Douglas's  pouch. 
This  was  kept  closed  by  a  cork  or  by  a  roll  of  carbolized  cotton,  and 
through  it  the  pelvic  cavity  was  syringed  out  with  carbolized  water,  carried 
in  by  a  catheter  if  symptoms  of  septicaemia  developed.  Since  the  use  of 
antiseptic  dressings  I  have,  however,  discarded  this,  and  now  employ  a 
double  tube  with  lateral  branches,  which  pass  out  through  the  antiseptic 
dressings.  This  renders  it  unnecessary  to  disturb  it  when  washing  out 
the  abdominal  cavity,  and  the  rubber  tubing  with  stopcocks  arranged  at 
the  extremities  of  the  lateral  arms  enables  us  to  exclude  air  very  perfectly. 
The  two  halves  of  the  tube  do  not  communicate.     As  it  is  forced  in  through 


746  OVARIOTOMY. 

one  lateral  branch,  the  fluid  runs  out  at  its  lowest  extremity,  rises  in  the 
cavity,  and  escapes  through  the  other  tube.  Obstructing  the  escape-tube 
will  more  completely  fill  the  cavity  with  fluid,  if  this  be  considered 
desirable. 

Fig.  261. 


Thomas's  drainage  tube  of  metal,  vulcanite,  or  glass. 

Closing  the  Wou?id. — This  is  accomplished  by  two  sets  of  sutures,  the 
deep  and  superficial.  The  first,  composed  of  silver,  may  be  passed  in  the 
following  manner  :  a  thread  of  silver  wire  is  passed  at  each  of  its  extremi- 
ties through  a  long  and  stout,  straight  needle.  One  of  the  needles,  being 
grasped  by  strong  needle-forceps,  is  passed  through  the  peritoneum  of  one 
abdominal  flap  near  the  edge  of  the  incision  and  made  to  emerge  through 
the  skin  about  an  inch  from  the  edge.  Then  the  other  needle  is  seized 
and  passed  through  the  other  side.  The  suture  is  then  secured  by  twisting. 
These  deep  sutures,  placed  at  the  distance  of  half  an  inch  apart,  will  bring 
the  whole  incision  into  contact  from  the  peritoneum  to  the  skin,  and  favor 
healing  by  first  intention. 

A  much  better  method  is  to  pass  through  both  walls  of  the  abdomen  a 
long  needle  with  fixed  handle  and  an  eye  near  its  point  armed  with  a  short 
loop  of  silk  as  recommended  by  Peaslee.  Into  this  loop  or  into  the  eye 
of  the  needle  a  bit  of  metallic  wire  is  fitted  and  immediately  drawn  into 
place. 

Besides  these,  superficial  sutures  or  pins  like  those  employed  for  harelip 
should  be  used,  which  pass  through  the  skin  and  areolar  tissue,  but  do  not 
involve  the  peritoneum.    Around  the  pins  thread  is  wrapped  in  figure  of  8. 

The  operation  having  been  performed  under  Lister's  method  throughout, 
the  wound  is  now  covered  with  his  antiseptic  dressing,  which  is  secured  in 
place  by  a  heavy  covering  of  carbolized  cotton,  and  this  again  by  a  firm 
bandage.  Then  the  patient  should  be  removed  from  the  table  to  her  bed, 
given  a  dose  of  opium  or  one  of  its  salts,  and  covered  up  warmly,  with 
warmth  to  the  feet  even  in  hot  weather.  It  is  well  to  move  the  patient  now 
to  another  room.  The  temperature  of  the  operating  room  should  have  been 
about  7.">°,  that  of  the  chamber  in  which  she  is  to  remain  should  be  less. 
This  apartment 'should  be  kept  at  a  temperature  of  G5°  to  G8°  Fahr.,  and 
thorough  ventilation  should  be  secured,  not  by  the  unpleasant  method 
of  admitting  cold,  damp,  and  chilling  air,  but  by  the  more  philosophical 


CLOSING    THE    WOUND.  747 

one  of  causing  the  rapid  escape  of  foul  air.  This  can  best  be  done  by 
lighting  a  fire  in  the  chimney,  by  immediate  removal  of  offensive  sub- 
stances, and  by  general  cleanliness. 

A  quiet,  attentive  nurse  who  understands  the  use  of  the  catheter  should 
be  in  attendance  day  and  night. 

The  effects  of  the  operation  upon  the  nervous  system  should  be  guarded 
against  by  the  means  just  enumerated  as  general  rules  of  management, 
and  by  administration  of  stimulants,  as  brandy  or  champagne,  if  the 
strength  appear  to  be  failing.  In  addition,  the  most  complete  quietude  of 
mind  and  body  should  be  afforded.  All  conversation  and  noise  should  be 
interdicted,  the  patient's  hopefulness  excited  and  fostered,  and  all  muscular 
effort  avoided.  For  four  or  five  days  the  catheter  should  be  employed  for 
evacuating  the  bladder,  and  the  bowels  be  kept  constipated  by  opium  for 
ten  days  or  a  fortnight.  The  avoidance  of  cathartics  during  this  time  is 
essential  to  safety,  a  neglect  of  this  precaution  often  producing  a  fatal  issue. 
Some  years  ago  I  was  present  at  the  removal  of  an  immense  cystic  sar- 
coma by  the  late  Dr.  John  O'Reilly,  who  made  an  incision  extending  from 
the  xiphoid  cartilage  to  the  symphysis,  and  after  detaching  many  adhesions 
extirpated  the  mass.  The  patient  did  perfectly  well  for  a  week,  and  was 
in  a  fair  way  to  recover.  She  was,  however,  very  urgent  that  her  bowels 
should  be  moved,  and  the  doctor  refusing  to  comply  with  her  solicitations, 
she  took  surreptitiously  a  full  dose  of  bitartrate  of  potash.  This  acted  as 
a  hydragogue  cathartic,  but  its  action  was  not  limited  as  it  usually  is. 
Diarrhoea,  and  soon  dysentery,  supervened  and  destroyed  the  patient's  life. 

After  the  seventh  or  eighth  day,  tympanites  may  call  for  an  alvine 
evacuation,  which  can  be  effected  by  an  ordinary  injection  of  soapsuds  or 
an  infusion  of  linseed,  chamomile,  or  fennel. 

The  patient  should  be  kept  quiet  and  free  from  pain  by  opium,  given 
either  by  the  mouth  or  rectum,  so  soon  as  she  has  rallied  from  the  anaes- 
thetic ;  or,  in  case  of  suffering,  by  the  hypodermic  method.  Her  nourish- 
ment should  consist  of  milk,  beef-juice,  or  gruel  with  milk.  Even  these 
digestible  substances  should  be  given  in  small  amounts  and  with  caution. 
Should  there  be  a  tendency  to  nausea  and  vomiting,  pieces  of  ice  may  be  held 
in  the  mouth  or  swallowed,  and  if  these  symptoms  be  so  severe  as  to  threaten 
rupture  of  the  sutures,  the  hypodermic  use  of  morphia  should  be  resorted  to. 

Should  any  marked  irritability  of  the  stomach  exist,  all  efforts  at  giving 
nutriment  by  that  viscus  should  at  once  be  stopped,  and  the  patient  be 
nourished  entirely  by  the  rectum.  From  two  to  three  ounces  of  mashed 
beef,  bullock's  blood,  or  strong  meat  essences,  should  be  given  every  two 
hours.  With  this  brandy  or,  as  Mr.  Thornton  advises,  port  wine  may  be 
given,  and  if  necessary  the  tincture  of  opium.  I  have,  in  many  cases,  had 
patients  nourished  almost  entirely  in  this  way  from  the  time  of  operation 
until  ten  days'  convalescence  have  been  parsed. 

The  evils  which  are  chiefly  to  be  feared  as  sequels  of  the  operation  are, 
within  the  first  twenty-four  hours,  hemorrhage  ;  from  second  to  fourth  day, 


748  OVARIOTOMY. 

peritonitis ;  from  completion  of  operation  to  third  or  fourth  day,  nervous 
prostration  ;  and  from  fourth  to  fourteenth  day,  septicaemia. 

Should  hemorrhage  be  ascertained  to  be  taking  place,  all  dressings  should 
be  at  once  removed,  and  the  stump,  if  out  of  the  abdomen,  securely  ligated 
or  touched  with  the  actual  cautery.  If  it  have  been  returned  to  the  abdo- 
minal cavity,  there  is  but  one  course  available,  that  is,  opening  the  wound, 
ligating  the  bleeding  vessel,  and  cleansing  the  peritoneal  cavity.  Such  a 
necessity  is  very  unfortunate,  yet  this  course  holds  out  the  only  prospect 
of  success.  Last  year  I  had  twice  to  resort  to  this  alternative,  and  both 
my  patients  recovered. 

Septicaemia,  which  is  now  admitted  to  be  the  most  frequent  cause 
of  death  after  ovariotomy,  is,  when  once  fully  established,  a  most  dan- 
gerous'state.  It  is  ushered  in  by  dizziness;  excessive  muscular  pros- 
tration ;  anorexia ;  great  pallor ;  high  temperature ;  small,  rapid,  and 
very  weak  pulse  ;  sometimes  a  low  delirium ;  dry  tongue ;  and  a  sweetish 
odor  of  the  breath.  It  is  this  condition  which  is  so  often  alluded  to  as  a 
"typhoid  state"  after  operations,  and  one  cannot  but  suspect  that  many, 
if  not  most,  of  those  cases  quoted  in  Dr.  Clay's  tables  as  shock  or  collapse, 
occurring  as  late  as  the  fifth,  sixth,  seventh,  and  tenth  days,  were  really 
instances  of  this  affection.  In  one  of  my  fatal  cases,  the  patient  was  doing 
quite  well  on  the  evening  of  the  seventh  day.  On  the  morning  of  the  eighth 
I  was  struck  by  her  wild,  maniacal  expression  and  cadaverous  countenance; 
upon  examination  I  found  all  the  symptoms  of  septicaemia  present,  and 
she  very  soon  succumbed  to  them. 

The  gravity  of  this  sequel  has  rendered  all  operators  anxious  to  possess 
the  means  to  avoid  or  remedy  it.  Most  of  the  methods  of  avoidance  have 
been  already  stated ;  the  importance  of  the  subject  will,  however,  excuse 
my  again  referring  to  them  as — 

1st.  Completely  cleansing  the  peritoneum; 

2d.  Checking  hemorrhage  before  closing  the  abdominal  wound ; 

3d.  Establishing  drainage,  whenever  fluids  are  likely  to  collect  in  the 
peritoneum  ; 

4th.  Adhering  strictly  to  Lister's  method. 

Septicaemia,  being  the  result,  first,  of  the  decomposition,  and,  second,  of 
the  absorption,  of  fluids  in  the  peritoneum,  is  not  likely  to  occur  for  several 
day?;,  but  it  may  take  place  two  or  three  weeks  after  the  operation. 

The  development  of  peritonitis  and  septicaemia  should  be  carefully 
looked  for.  All  the  rational  and  physical  signs  which  mark  them  should  be 
constantly  investigated,  and  their  inception  be  met  by  appropriate  thera- 
peutic means.  A  written  record  of  pulse-rate,  temperature,  and  number 
of  respirations  should  be  systematically  kept,  an  entry  being  made  as  to 
the  three  conditions  at  least  as  often  as  every  six  or  eight  hours.  In  case 
a  competent  assistant  remain  at  the  bedside,  it  may  be  done  more  fre- 
quently, but  never  often  enough  to  annoy  or  harass  the  patient. 

After  the  lapse  of  twelve  hours,  in  consequence  of  the  anaesthetic,  the 


CLOSING    THE    WOUND. 


749 


vomiting  which  this  commonly  induces,  and  the  effect  of  a  capital  surgical 
operation  upon  the  nervous  system,  the  pulse  usually  runs  up  to  1 10  or  even 
120,  and  the  temperature  to  102°  or  103°,  hut  as  the  irritative  influence 
of  these  agencies  passes  off  a  subsidence  ordinarily  occurs,  the  pulse 
ranging  from  90  to  105,  and  the  temperature  from  99°  to  101°  as  con- 
valescence proceeds. 

If  at  any  time  the  temperature  should  gradually  or  suddenly  advance  to 
103°,  104°,  or  10o°,  except  just  as  ihe  patient  rallies  from  the  imme- 
diate effects  of  anaesthesia  and  operation,  fears  should  be  entertained  that 
peritonitis  or  septicaemia  is  developing.  If  it  occur  within  four  days  after 
operation,  it  is  likely  to  be  the  former.  If  after  that  time,  the  probabili- 
ties are  greatly  in  favor  of  the  latter.  The  pulse  will  usually  become 
rapid  at  the  same  time  whichever  morbid  condition  is  developing,  and  it 
must  not  be  forgotten  that  the  two  are  often  combined. 

I  have  already  stated  that  in  cases  in  which  fluid  remains  in  the  peri- 
toneal cavity,  or  collects  there  subsequent  to  operation,  it  is  my  custom  to 
pass  to  the  very  bottom  of  Douglas's  cul-de-sac  the  tube  elsewhere  shown, 
Through  this,  should  the  temperature  run  up,  I  inject  warm  carbolized  water 
once  or  twice  in  every  twenty-four  hours.  In  no  instance  have  I  seen  evil 
result  from  this  course.  Even  where  a  tube  has  not  thus  been  left  in  place, 
when  the  temperature  or  pulse  rises  and  the  other  symptoms  of  septicaemia 
develop,  such  an  injection  may  often,  with  advantage,  be  practised  once  in 
every  eight  hours.  But  without  the  tube  left  from  the  time  of  operation, 
it  is  difficult  and  sometimes  impossible  to  reach  the  most  dependent  part  of 
the  peritoneum,  and  hence  I  urge  its  employment. 

The  following  tabulated  record  of  temperature  taken  by  Dr.  Kuentzler, 
in  a  desperately  bad  case  of  double  ovariotomy  occurring  in  my  practice, 
will  show  what  marked  variations  may  occur,  what  elevations  may  be 
reached  and  yet  the  patient  recover,  and  how  decided  is  sometimes  the 
effect  of  antiseptic  injections  into  the  pelvic  cavity  in  rapidly  lowering  the 

animal  heat. 

Fig.  262. 
J)i\ieJuhy2  f.J  /'/  fs  <6  /?  ts  19  20  zi  22  2324  25  2s  27  zx  2ti  .v>  31 

.         •  <       1      ] r 1    ■!      1       1  1      j      1      '       1      !       1 


750 


OVARIOTOMY. 


Fio.  263. 


21  \22\2A  f4\2J\S6\27',Z8\29\30\3l  |«LuLs*  3f\x\37\.W  V  >,0 


Fig.  264. 


patBjjftto&is 

n 

2* 

25  26  21 

2<f  2.9 

30 

3/ 

f« 

JE 

3 

4- 

S 

6 

7 

a 

.9 

days  or 

OISIASE 

*/J4* 

m 

44\fi5\46\»7\*S 

0 

1 

50 

.;/ 

12 

S3 

5*r 

— i ' 

55  56 

*7 

ss\j» 

m  \ 

-J 

NO 

(fcu> 

:>« 

hi* 

St* 

s* 

i 

«& 

/02> 

T 

tmfrtrcilui 

•e 

<akt 

•*//  < 

a  i 

>/u 

nti 

uih 

for 

MO' 

ft 

I 

i  j 

/ 

\e     * 

'i 

.9 

99* 

I  V 

r    \\ 

Y 

i 

X\ 

\  S 

kf 

\t 

^ 

j     i 

r 

.9/9' 
S7" 

e 

s 

V 

v  \ 

6      \l 

J 

9 

1 

f 

,9€» 

JK 

B  Ti*  siarJt  indicdte 

1 1 L    .  I     ,  1       i 

'Ji&Wai 

hmgoi 

ftili 

vp 

,/it 

ma 

ittv. 

Let  no  one  suppose  that  septicemia  once  established  becomes  irremedia- 
ble. Experience  disproves  this ;  it  is  the  prolongation  of  exposure  to  absorp- 
tion of  septic  elements  that  constitutes  the  great  danger  of  the  condition. 

This  method  of  meeting  in  an  efficient  and  satisfactory  manner  the  most 
fruitful  source  of  danger  after  ovariotomy,  I  regard  as  second  in  impor- 
tance to  no  other  improvement  which  has  been  introduced  since  the  dis- 
covery of  the  operation  itself.  It  emanated  from  Dr.  E.  R.  Peaslee,  and 
has  even  now,  I  think,  not  assumed  its  legitimate  position  in  the  scale  of 
importance. 

It  is  a  matter  of  moment,  in  reference  to  this  method,  to  know  how  an 
experience  of  fifteen  years  in  its  use  should  have  affected  its  originator 
towards  it.  In  an  article  written  in  1870,  he  expressed  the  following 
conclusions : — 

"1.  Intra-peritoneal  injections  of  water,  with  the  addition  of  liq.  soda? 
chlorinat.  or  carbolic  acid,  as  before  explained,  are  entirely  safe  after  ovari- 
otomy in  the  conditions  requiring  them. 


AFTER-TREATMENT.  751 

*'  2.  They  should' be  used  with  a  curative  intention  in  all  cases  of  septicae- 
mia already  developed,  and  in  all  cases  for  prevention  where  it  is  feared, 
from  the  presence  already  of  a  fluid  in  the  peritoneal  cavity,  whose  decom- 
position will  produce  it. 

"3.  Thus  used,  they  will  diminish  the  percentage  of  deaths  from  septi- 
caemia after  ovariotomy  from  one-sixth  (seventeen  and  eleven-seventeenths 
per  cent.)  of  all  who  die  after  it,  to  one-thirty-sixth  (two  and  sixteen- 
seventeenths  percent.);  and  increase  the  average  success  of  ovariotomy 
from  seventy  to  seventy-four  or  seventy-five  per  cent. 

"4.  Intra-peritoneal  injections  are  never  to  be  thought  of  except  for  the 
purpose  of  removing  a  fluid  already  in  the  peritoneal  cavity,  which  either 
has,  or  assuredly  will  have,  produced  septicaemia. 

"  5.  A  tent  may  be  inserted  for  two  to  four  days  at  the  lower  end  of  the 
incision,  with  entire  safety,  in  any  case  of  ovariotomy  where  the  accumula- 
tion of  such  fluid  is  apprehended. 

"  G.  Finally,  septicaemia  would  more  rarely  occur  after  ovariotomy  if  all 
fluid  were  removed  from  the  peritoneal  cavity  by  the  most  careful  sponging 
before  closing  the  incision." 

Peritonitis,  which  proves  the  cause  of  death  to  many  of  those  who  die 
from  this  operation,  is  best  avoided  by  leaving  as  few  ligatures  as  possible 
in  the  peritoneal  cavity,  by  removal  of  all  putrefactive  matters,  by  keep- 
ing the  abdominal  viscera  at  rest  by  preventing  vesical  and  rectal  action, 
and  by  complete  antisepsis. 

Should  peritonitis  develop,  it  should  be  at  once  treated  by  free  and 
steadily  continued  use  of  opium,  after  the  plan  of  Alonzo  Clark.  The 
bowels  should  be  kept  strictly  constipated,  the  patient  perfectly  quiet  upon 
the  back,  the  diet  be  restricted  to  milk,  and  no  other  medicine  than  opium 
be  administered.  A  difference  of  opinion  exists  as  to  the  benefit  arising 
from  applications  over  the  abdomen.  Mine  is,  that,  as  a  rule,  stupes  of 
turpentine,  bladders  of  ice,  and  warm  poultices,  alike  do  harm.  In  cases 
where  the  disease  is  limited  to  the  pelvis  the  last  often  do  good,  but  in 
general  peritonitis  the  comfort  of  the  patient  appears  to  be  favored  by  an 
avoidance  of  them. 

Should  peritonitis  arise  after  the  lapse  of  four  or  five  days,  it  should,  I 
think,  be  looked  upon  as  a  septic  peritonitis  due  to  putrefaction  of  con- 
tained fluids,  and  it  is  a  question  whether  such  cases  should  not  be  treated 
in  their  very  inception  by  peritoneal  injections.  Should  it  arise  still  later, 
for  instance,  about  the  tenth  or  twelfth  day,  it  should  be  looked  upon  as  a 
result  of  discharge  into  the  peritoneum  of  encapsulated  fluid  material, 
and  might  likewise  be  met  in  this  way,  particularly  if  injection  can  be 
accomplished  without  reopening  the  abdominal  wround.  It  is  to  avoid  this 
necessity  that  I  employ  a  drainage  tube  in  appropriate  cases. 

In  a  patient  exposed  to  the  dangers  of  ovariotomy  the  temperature  is 
a  matter  of  the  greatest  moment,  and  its  excessive  elevation  often  proves 


752  OVARIOTOMY. 

of  itself,  that  is,  without  the  full  and  fatal  development  of  peritonitis  or 
septicaemia,  the  cause  of  death. 

The  establishment  upon  a  firm  and  enduring  basis  of  clinical  thermo- 
metry, as  an  adjuvant  to  the  practice  of  medicine  and  surgery,  constitutes 
one  of  the  most  important  advances  which  has  marked  the  nineteenth 
century,  prolific  as  it  has  been  in  progress.  No  longer  like  his  fore- 
fathers, groping  in  the  dark  and  dealing  with  surmises  and  conjectures, 
the  practitioner  of  to-day  finds  the  former,  both  in  diagnosis  and  prognosis, 
replaced  by  certainty  and  the  latter  by  scientific  deduction.  By  the  aid 
of  this  accurate  method  he  watches  his  patient's  progress  from  day  to  day, 
nay,  even  from  hour  to  hour,  with  the  calm  confidence  of  one  who  has  a 
reliable  knowledge  of  the  present  and  a  certainty  that  he  will  be  fore- 
warned as  to  the  future. 

But  it  is  not  only  in  reference  to  diagnosis  and  prognosis  that  thermo- 
metry aids  us  at  the  bedside.  It  having  been  observed  that  prolonged 
high  temperature  kills ;  that,  the  animal  heat  being  kept  for  days  at  106°, 
the  patient  almost  invariably  succumbs,  the  knowledge  of  this  fact  natu- 
rally suggested  the  adoption  of  means  which,  even  although  they  did  not 
cure  the  existing  disorder,  lowered  the  high,  rate  of  temperature,  and 
barred  at  least  this  avenue  to  the  approach  of  death. 

The  importance  of  doing  this  has  been  recognized  by  ovariotomists,  and 
partial  results  have  been  obtained  by  the  use  of  quinine  in  large  doses, 
the  administration  of  salicylic  acid,  alone  or  in  combination  with  soda, 
and  the  application  to  the  head  of  the  ice-bag  of  Wells.  Struck  by  the 
very  apparent  inefficiency  of  these  means,  I  have  for  some  time  been 
endeavoring  to  adopt  some  plan  by  which  refrigeration  of  the  trunk  could 
be  effected  without  the  necessity  of  exhausting  my  patient  by  removal 
from  the  bed;  and  the  "cold  pack,"  sponging,  and  the  apposition  of  wet 
cloths  were,  in  turn,  tried.  The  use  of  the  cold  bath  I  likewise  considered, 
but  the  idea  was  at  once  abandoned;  for  the  removal  of  a  patient  re- 
cently exposed  to  laparotomy  from  her  bed  to  the  tub  was  attended  by 
risks  which  evidently  must  be  much  greater  than  those  attending  the 
same  process  in  an  ordinary  case.  The  difficulties  presenting  themselves 
had  well-nigh  caused  me  to  forego  all  hope  of  employing  this  means  of 
combating  hyperpyrexia,  when  the  late  Dr.  G.  W.  Kibbee  brought  to  my 
notice  an  ingenious  device  of  his  for  accomplishing  the  desired  result.  He 
placed  the  patient  upon  what  he  called  his  "fever  cot,"  which  I  here 
exhibit  and  describe  in  the  words  in  which  he  advertised  his  invention. 

Upon  this  cot  a  folded  blanket  is  laid  so  as  to  protect  the  patient's  body 
from  cutting  by  the  cords  of  the  netting,  and  at  one  end  is  placed  a  pillow 
covered  with  India-rubber  cloth,  and  a  folded  sheet  is  laid  across  the  mid- 
dle of  the  cot  about  two-thirds  of  its  length.  Upon  this  the  patient  is  now- 
laid,  her  clothing  is  lifted  up  to  the  armpits  and  the  body  enveloped  by 
the  folded  sheet,  which    extends  from    the  axillae  to  a  little  below  the 


AFTER-TREATMENT. 


753 


trochanters.     The  legs  are  covered  by  flannel  drawers,  and  the  feet  l»y 
warm  woollen  stockings,  and  against  the  soles  of  the  latter  bottles  of  warm 


Fig.  265. 


"The  bed  on  which  the  patient  lies  consists  of  a  strong  elastic,  cotton  netting,  manufactured  for 
the  purpose,  through  which  water  readily  passes  to  the  bottom  below,  which  is  of  rubber  cloth, 
so  adjusted  as  to  convey  it  to  a  vessel  at  the  foot.  When  not  in  use  it  can  be  close  folded  so  as 
to  occupy  but  little  space." 

water  are  placed.  Two  blankets  are  then  placed  over  her,  and  the  appli- 
cation of  water  is  made.  Turning  the  blankets  down  below  the  pelvis,  the 
physician  now  takes  a  large  pitcher  of  water  at  from  75°  to  80°  and  pours 
it  gently  over  the  sheet.  This  it  saturates,  and  then,  percolating  the  net- 
work, it  is  caught  by  the  India-rubber  apron  beneath,  and,  running  down 
the  gutter  formed  by  this,  is  received  in  a  tub  placed  at  the  extremity  of  the 
cot  for  that  purpose.  Water  at  higher  or  lower  degrees  of  heat  than  this 
may  be  used.  As  a  rule,  it  is  better  to  begin  with  a  high  temperature, 
8o°  or  even  90°,  and  gradually  diminish  it. 

The  patient  now  lies  in  a  thoroughly  soaked  sheet  with  warm  bottles  to 
her  feet,  and  is  covered  up  carefully  with  dry  blankets.  Neither  the  por- 
tion of  the  thorax  above  the  shoulders  nor  the  inferior  extremities  are  wet 
at  all.  The  water  is  applied  only  to  the  trunk.  The  first  effect  of  the 
aifusion  is  often  to  elevate  the  temperature,  but  the.  next  affusion,  practised 
at  the  end  of  an  hour,  pretty  surely  brings  it  down.  It  is  better  to  pour 
water  at  a  moderate  degree  of  coldness  over  the  surface  for  ten  or  fifteen 
minutes  than  to  pour  a  colder  fluid  for  a  shorter  time.  The  water  slowly 
poured  robs  the  body  of  heat  more  surely  than  when  used  in  the  other  way. 
The  water  collected  in  the  tub  at  the  foot  of  the  bed,  having  passed  over 
the  body,  is  usually  8°  or  10°  warmer  than  it  wras  Avhen  poured  from  the 
pitcher.  On  one  occasion  Dr.  Van  Vorst,  late  house-surgeon  to  the 
Woman's  Hospital,  tells  me  that  it  gained  12°. 

At  the  end  of  every  hour  the  result  of  the  affusion  is  tested  by  the 
thermometer  ;  and,  if  the  temperature  have  not  fallen,  another  affusion  is 
practised,  and  this  is  kept  up  until  the  temperature  comes  down  to  100° 
or  even  less. 

It  must  be  appreciated  that  the  patient  lies  constantly  in  a  cold,  wet 
sheet ;  but  this  never  becomes  a  fomentation,  for  the  reason  that,  as  soon 
48 


754  OVARIOTOMY. 

as  it  abstracts  from  the  body  sufficient  heat  to  do  so,  it  is  again  wet  with 
cold  water  and  goes  on  still  with  its  work  of  heat  abstraction.  I  have 
kept  patients  upon  this  cot  enveloped  in  the  wet  sheet  for  two  and  three 
weeks  without  discomfort  to  them  and  with  the  most  marked  control  over 
the  degree  of  animal  heat.  Ordinarily,  after  the  temperature  has  come 
down  to  99°  or  100°,  four  or  five  hours  will  pass  before  affusion  again  be- 
comes necessary. 

This  device  of  Dr.  Kibbee  is  so  simple  that  one  wonders  that  any  per- 
plexity attended  his  accomplishing  all  that  it  does  before  it  was  shown  to 
him,  and  at  once  the  thought  suggests  itself  how  easily  a  substitute  for 
it  could  be  improvised.  It  is  the  old  story  of  the  egg  of  Columbus. 
The  idea,  once  suggested,  by  its  very  simplicity  assumes  its  place  in  the 
mind  as  a  familiar  one.  Simple  as  it  is,  it  affords  the  means  of  using  a 
most  important  therapeutic  resouree,  and,  in  my  estimation,  leaves  nothing 
to  be  desired  in  this  respect.  Recognizing  in  this  a  method  by  which  cold 
could  be  applied  to  the  surface  for  any  length  of  time  without  fatigue  or 
exhaustion  to  the  patient  and  without  the  danger  of  excessive  chilling, 
since  any  great  depression  of  temperature  can  be  obviated  by  the  affu- 
sion of  warm  water,  I  determined  at  once  to  adopt  it  after  ovariotomy. 

In  adopting  this  plan  of  treatment  after  ovariotomy,  and  as  I  have  in 
several  cases  done  after  parturition,  I  did  not  propose  by  it  to  check  peri- 
tonitis, or  to  cut  short  septicaemia,  the  great  evils  to  be  feared  at  this  time. 
My  hope  was  to  rob  these  diseases  of  one  of  their  chief  weapons  of  de- 
struction— hyperpyrexia,  and  thus  to  resist  the  primary  assault  in  the 
hope  of  bearing  up  against  a  more  prolonged  though  less  violent  siege. 

In  all  acute  and  grave  diseases,  the  invasion  of  the  disorder  produces 
great  commotion,  which  rapidly  subsides  as  the  system  becomes  familiar- 
ized with  the  invading  ailment.  This  is  most  marked  in  pneumonia, — and 
to  a  less  degree  in  peritonitis  and  septicaemia,  if  the  patient  does  not  suc- 
cumb very  early.  How  often  has  every  ovariotomist  been  surprised,  in 
making  an  autopsy  of  a  patient  who  has  apparently  died  of  acute  perito- 
nitis, to  find  only  a  slight  field  of  pelvic  peritonitis  which  most  unsatis- 
factorily accounts  for  the  destruction  of  life  ! 

Robbed  of  its  lengthy  and  wearing  high  temperature,  which  lasts  for 
weeks,  depraving  the  blood,  altering  the  nerve  centres,  and  degenerating 
the  muscles,  typhoid  fever  runs  a  much  more  manageable  and  less  violent 
course.  So  septicaemia  and  peritonitis,  kept  from  the  commencement  of 
their  courses  within  normal  limits  as  to  temperature,  are  wonderfully 
different  in  their  manifestations  from  the  same  diseases  uninterfered  with 
in  this  respect.  Under  these  circumstances  the  system  of  the  patient  may 
be  likened  to  a  city  exposed  to  attack  from  an  armed  foe.  The  great 
danger  is  from  the  first  assault;  but,  once  having  resisted  that,  its  prospects 
of  holding  out  against  a  siege  would  be  good,  although  in  the  end  it  might 
yield  even  to  this.     Still  the  prospects  of  successful  defence  would   be 


AFTER-TREATMENT.  755 

greatly  increased  if  the  primary,  most  energetic,  and  most  vigorous  at- 
tack were  defeated. 

I  have  now  employed  this  method  very  freely  for  more  than  a  year,  and 
my  confidence  in  it  increases  with  growing  experience.  I  would  alter  but 
one  statement  concerning  it  which  I  have  formerly  made;  that  is,  I  do 
not  now  often  use  water  at  very  low  temperatures,  but  usually  at  90°, 
lowering  it  gradually  to  80°. 

As  to  the  time  at  which  the  sutures  should  be  removed,  no  fixed  rule 
can  be  given,  for  it  will  depend  upon  the  rapidity  and  completeness  of 
union.  Should  union  by  first  intention  occur,  some  of  them  may  be 
removed  on  the  sixth,  seventh,  or  eighth  day.  But  great  care  should 
always  be  observed,  and  only  those  at  points  where  the  union  is  strong 
should  be  withdrawn.  After  withdrawal  the  abdomen  should  be  firmly 
supported  by  adhesive  plaster.  The  clamp,  if  employed,  or  the  ligature, 
if  passed  out  through  the  wound,  should  be  removed  when  they  lose  their 
hold  by  reason  of  sloughing,  and  incline  to  fall  off.  No  traction  should  be 
applied  to  them.  A  case  was  recently  reported  before  a  society  in  London 
in  which  too  early  removal  of  the  clamp  had  resulted  in  obstinate  protru- 
sion of  a  knuckle  of  intestine,  which  produced  fatal  peritonitis.  Mr. 
"Wells  used  it  as  a  text  by  which  to  urge  that  the  clamp  should  always  be 
left  in  place  until  it  was  ready  to  drop  off.  This  will  usually  be  about  the 
ninth  or  tenth  day. 

The  patient  should  be  cautioned  against  rising  too  early  after  convales- 
cence. Even  after  she  is  able  to  go  about  she  should  be  very  careful  not 
to  make  any  violent  efforts,  and  for  a  year  or  two  she  should  wear  a  well- 
fitting  abdominal  corset  to  guard  against  ventral  hernia.  I  have  had  this 
occur  in  several  cases.  The  abdominal  walls  were  separated  over  a  space 
measuring  about  four  inches,  and  the  intestines  were  supported  only  by 
skin,  areolar  tissue,  and  peritoneum.  In  one  case  these  yielded  to  pres- 
sure, and  one  year  after  ovariotomy  a  tumor  about  the  size  of  a  kidney, 
with  a  mass  of  attached  omentum,  escaped. 

The  occurrence  of  ventral  hernia  is  not  the  result  of  any  bad  manage- 
ment on  the  part  of  the  operator.  It  may  occur  in  any  case,  and  some- 
times comes  on  when  no  operation  has  been  performed. 


756  OOPHORECTOMY. 


CHAPTER    L. 

OOPHORECTOMY. 

Synonyms This  operation  has  been  styled  female  castration,  spaying, 

and  Battey's  operation. 

History. — As  the  creation  of  the  male  eunuch  by  removal  of  the  testicles 
has  long  been  known  as  a  procedure  practised  for  other  than  scientific  pur- 
poses, so  probably  has  that  of  the  female  eunuch  by  removal  of  the  ovaries. 
The  former  procedure  was,  however,  very  commonly  put  into  practice; 
the  latter  very  rarely  so.  The  former  is  substantiated  by  unquestion- 
able evidence  ;  the  latter  rests  merely  upon  vague  tradition,  which  asserts 
that  a  king  of  Lydia  had  it  practised  upon  a  lewd  daughter,  and  that  in 
India  female  eunuchs  were  thus  created  in  the  olden  time. 

In  the  lower  orders  of  animals  spaying  has  long  been  very  extensively 
practised,  and  is  so  to-day. 

In  1823  James  Blundell,  of  London,  formally  suggested  the  practice  of 
this  operation  in  a  paper  presented  to  the  Royal  Society  of  Medicine  and 
Surgery  of  London.  In  this  he  suggested  that  the  extirpation  of  the 
healthy  ovaries  would  probably  prove  remedial  for  severe  dysmenorrhea 
and  for  the  menorrhagia  which  accompanies  inversion  of  the  uterus  where 
amputation  is  not  practicable. 

In  1872  Dr.  Robert  Battey,  of  Georgia,  performed  the  operation  for 
removal  of  the  healthy  ovaries  for  the  premature  production  of  the  meno- 
pause. He  was  soon  followed  by  Hegar,  of  Germany,  who  has  since  not 
only  contributed  more  than  any  other  to  the  clinical  history  of  the  subject, 
but  has  likewise  done  more  than  any  predecessor  or  contemporary  for  the 
scientific  elucidation  of  the  procedure.  His  name  is  indeed  almost  as 
much  associated  with  the  operation  as  that  of  its  originator,  Battey. 

Theory  of  the  Operation Dr.  Battey,  basing  his  reasoning  upon  the 

fact  that  ovulation  is  the  cause  of  menstruation,  with  all  its  accompanying 
pelvic  engorgement  and  nervous  exaltation,  drew  the  deduction  that  extir- 
pation of  the  ovaries  by  putting  a  stop  to  ovulation,  would  check  its  con- 
sequence, menstruation,  and  that  thus  many  evils  dependent  upon  these 
two  processes  would  by  it  be  cured.  Such  was  his  conclusion,  and  to  test 
the  question  he  began  practising  the  procedure.  Very  soon  he  was  fol- 
lowed by  others,  so  that  now  the  operation  is  recognized  as  a  surgical 
resource  in  every  civilized  country,  and  sufficient  testimony  is  in  existence 
from  which  to  draw  conclusions  as  to  its  propriety. 


THEORY    OF    THE    OPERATION.  757 

Indications. — Ovarian  extirpation  is  recommended  for  the  following 
conditions: — 

Severe  dysmenorrhea  ; 

Excessive  menorrhagia ; 

Insanity  occurring  at  timus  of  ovulation  ; 

Ilystero-epilepsy  ; 

Excessive  hemorrhage  with  uterine  tumors ; 

Ilystero-neuroses,  other  than  epilepsy  of  severe  character; 

Chronic  ovaritis  with  severe  symptoms  ; 

Absence  of  vagina  or  uterus,  the  ovaries  being  present. 
Of  course  the  surgeon  would  have  to  decide  according  to  his  judgment 
and  his  conscience  whether  the  evils  for  which  he  proposed  operating  were 
of  so  grave  a  character  as  to  warrant  his  exposing  his  patient  to  a  pro- 
cedure of  the  gravity  which  the  sequel  will  prove  this  to  be. 

The  difficulties,  the  dangers,  and  the  doubtful  results  of  Battey's  opera- 
tion render  it  one  to  be  avoided  until  all  other  resources  have  been  tried, 
but  when  these  have  been  exhausted  and  death,  or  what  is  oftentimes 
worse,  a  life  of  suffering,  becomes  the  certain  fate  of  the  patient,  it  offers 
itself  as  a  resource  of  great  value. 

Results.1 — In  February  last  a  table  was  published  giving  the  results  in 
130  cases  in  which  this  operation  has  been  performed,  and  since  that  time 
five  others  have  been  reported.  Of  these  106  recovered  and  29  died, 
giving  us  a  mortality  of  a  little  over  21  per  cent. 

Unfortunately  not  all  those  who  recovered  from  the  operation  were 
cured  by  it  of  the  evils  for  which  it  was  endured.  Munde  very  justly 
remarks,  "if  the  positive  benefits  of  the  operation  were  as  assured  as  its 
rate  of  recovery,  the  opposition  to  it  would  soon  cease."  Of  24  patients 
who  recovered  from  the  operation,  Simpson2  reports  that  2  received  no 
benefit,  that  11  were  greatly  improved,  and  that  9  only  were  entirely 
cured.     Of  the  remaining  2  he  makes  no  mention. 

Names  of  those  who  have  operated — In  estimating  the  degree  of  favor 
with  which  a  new  operation  has  been  received,  a  great  deal  can  be  gathered 
from  a  survey  of  the  names  of  those  who  have  performed  it.  The  table 
which  I  here  subjoin  will  present  this  at  a  glance,  at  the  same  time  that 
it  will  show  the  number  of  times  that  laparotomy  and  elytrotomy  have 
been  selected. 

!  Archives  of  Medicine,  vol.  iv.,  No.  1,  Feb.  1880. 
2  British  Med.  Jour.,  May  24,  1879. 


758 


oophorectomy. 


Total. 

Laparotomy. 

Elytrotomy. 

Recov- 
eries. 

Deaths. 

Recov- 
eries. 

Deaths. 

Hegar 
Schroeder 

42 
2 

35 

2 

7 

Freund    . 

4 

3 

1 

v.  Langenbeck 

1 

1 

Martin     . 

3 

3 

Miiller 

3 

3 

Czerny     . 
Schucking 
Battey     . 
Trenholme 

3 

1 

12 

2 

2 
1 
2 
1 

1 

8 
1 

2 

Goodell    . 

6 

1 

1 

3 

1 

Sims 

7 

2 

1 

4 

Engleman 

3 

3 

Thomas    . 

2 

i 

1 

Peaslee    . 

1 

1 

Sabine 

1 

i 

Von  Nussbaum 

1 

i 

Tauffer    . 

1 

l 

Netzel 

1 

... 

1 

Pernice    . 

2 

2 

Alberts    . 

1 

... 

1 

Spencer  Wells 

1 

1 

Simpson  . 
Kaltenbach 

1 
1 

1 

1 

J.  (Jilmore 

1 

i 

Martin 

2 

2 

Pallen      . 

1 

1 

E.  KoeberlS 

1 

i 

W.  C.  Frew      . 

1 

l 

Prince 

1 

1 

Welponer 
Esmarch  . 

1 
1 

i 

l 

Tait 

2 

2 

West 

1 

... 

1 

Sims 

3 

*3 

Noeggerath 
Hunter  McOuire 

11 

2 

8 
2 

3 

Lusk 

1 

1 

Tyng        . 
Savage     . 
Mann 

1 

1 
1 

1 
1 

1 

Borner    . 

1 

"i 

135 

89 

23 

17 

4 

Mr.  Lawson  Tait  reports  in  the  British  Medical  Journal  for  July,  1880, 
28  operations  of  oophorectomy,  which  he  had  performed  within  the  twelve 
months  previous.  Of  these  25  were  complete  operations,  with  only  1 
death  ;  in  the  other  2  cases  he  failed  to  remove  the  ovaries  entirely,  and 
of  these  1  recovered  and  1  died. 

Methods  of  Operating — The  ovaries  may  be  extirpated,  either  by  cut- 
ting through  the  vagina  into  the  peritoneal  cavity,  elytrotomy;  or  by 
cutting  through  the  abdominal  walls,  laparotomy.      The  statistical  evi- 


ESTIMATE    OF    BATTEY'S    OPERATION.  759 

dence  is  somewhat  in  favor  of  the  former  of  these,  but  the  difficulties,  the 
uncertainty  of  success,  and  the  possibility  of  cutting  into  the  rectum  make 
the  latter  decidedly  preferable,  except  in  certain  exceptional  cases  which 
will  soon  be  mentioned.  In  a  number  of  cases,  even  after  elytrotomy,  it 
has  been  found  impossible  to  remove  the  ovaries,  which  were  hidden  away 
under  masses  of  effused  lymph,  and  as  a  secondary  procedure  laparotomy 
has  been  resorted  to.  I  should,  from  my  experience,  offer  this  rule  as  to  the 
choice  of  operation.  If  the  ovaries  can  be  distinctly  felt  as  movable  bodies 
in  the  pouch  of  Douglas,  elytrotomy  should  be  preferred ;  if  they  cannot 
be  felt  there,  and  if  signs  of  old  pelvic  inflammation  can  be  discovered, 
laparotomy  should  be  selected  as  the  most  reliable  and  safe  procedure. 

Should  elytrotomy  be  preferred,  the  patient  may  be  placed  in  Boze- 
man's  position,  as  shown  in  Fig.  256,  and  the  perineum  be  lifted  by  Sims's 
speculum  ;  or  upon  the  back,  in  a  modified  Simon's  position,  Fig.  102,  and 
the  perineum  be  drawn  down  by  the  same  speculum.  Then  the  vagina 
being  pulled  down  by  a  tenaculum  fixed  in  it  near  its  junction  with  the 
cervix,  it  should  be  cut  through  by  scissors,  the  ovaries  hooked  down  by 
the  finger,  drawn  into  the  vagina,  their  ligaments  ligated  by  carbolized  silk 
or  catgut,  returned  to  the  pelvis,  and  the  vaginal  opening  closed  by  suture. 

Laparotomy  should  be  performed  as  in  ovariotomy,  the  ovaries  lifted,  their 
ligaments  tied,  and  the  ligated  pedicle  dropped  back  into  the  abdomen. 

The  operation  which  is  selected  should  be  performed  under  the  anti- 
septic method,  and  the  after  treatment  of  the  patients  should  be  the  same 
as  after  ovariotomy,  to  which  the  reader  is  referred  for  details. 

Estimate  of  Battey's    Operation In  concluding  this   subject  let   me 

express  my  views  concerning  this  procedure  in  a  series  of  propositions. 

1st.  Battey's  operation  will,  by  reason  of  the  fact  that  there  is  a  class 
of  cases,  the  great  sufferings  attached  to  which  can  be  relieved  only  by  the 
cessation  of  ovulation  and  menstruation,  survive  all  opposition,  and  exist 
in  the  future  as  a  surgical  resource  of  great  value. 

2d.  It  is  an  operation  attended  by  grave  dangers,  and  by  doubtful  bene- 
fits.    Nevertheless,  the  chances  are  greatly  in  favor  of  its  affording  relief. 

3d.  It  will  ever  prove  more  difficult  and  dangerous  than  ovariotomy, 
because  pelvic  peritonitis  will  frequently  be  found  to  exist  in  cases  demand- 
ing it ;  because  the  ligature  of  the  pedicle  must  often  take  place  deep  down 
in  the  pelvis ;  because  the  abdominal  walls,  instead  of  being  stretched  as 
in  ovariotomy,  are  contracted  and  resisting ;  because  the  removal  of  the 
ovary  often  involves  tearing  the  surrounding  tissues ;  and  because  the 
abdominal  peritoneum  has  not  been  prepared  for  interference  by  friction 
from  a  large  tumor  as  it  has  been  before  ovariotomy. 

4th.  While  the  practice  of  the  operation  for  checking  menstruation 
where  vagina  and  uterus  are  absent  is  fully  sustained,  it  is  very  doubtful 
whether  benefit  will  result  from  it  in  cases  of  large  uterine  fibroids. 

5th.  A  greater  degree  of  surgical  skill  is  necessary  for  the  successful 
performance  of  this  operation  than  for  ovariotomy. 


760  DISEASES    OF    THE    FALLOPIAN   TUBES. 


CHAPTER    LI. 

DISEASES  OF  THE  FALLOPIAN  TUBES. 

Anatomy. — The  identity  of  structure  of  the  Fallopian  tubes  and  uterus 
will  be  appreciated  by  the  study  of  the  formation  of  these  organs  in  the 
embryo,  as  described  by  recent  observers,  more  especially  by  Leukart, 
Thiersch,  and  Kolliker. 

In  the  walls  of  the  Wolffian  body,  situated  near  the  kidneys,  on  each 
side,  in  the  female  embryo,  a  narrow  canal  develops  which  ends  below  in 
the  two  horns  of  the  uterus,  while  the  distal  extremity  performs  "  a  move- 
ment of  rotation  from  before  backwards,  and  from  above  downwards  ;  the 
whole,  together  with  the  ligaments  of  the  ovaries  and  the  round  ligaments, 
being  enveloped  in  double  folds  of  the  peritoneum,  which  enlarge  with 
the  growth  of  the  parts  themselves,  and  constitute  finally  the  broad  liga- 
ments of.  the  uterus."1  Coming  together  at  the  median  line  these  canals 
coalesce,  or  undergo  fusion,  forming  the  lower  portion  of  the  uterus,  and 
the  entire  vagina  down  to  the  hymen.  The  fundal  arch  is  now  formed  in 
all  probability  from  fusion  progressing  from  below  upwards,  although  this 
is  somewhat  doubtful.  Thiersch2  thinks  from  observation  on  the  embryos 
of  sheep  that  it  occurs  from  below  upwards ;  while  Kolliker,  who  experi- 
mented on  those  of  cattle,  believes  that  it  occurs  from  the  centre.  Prof. 
Dohm,  who  experimented  upon  embryonic  foxes,  sheep,  pigs,  and  cattle, 
concludes  that  it  begins  between  the  middle  and  lower  third,  and  extends 
upwards  and  downwards.  All  this  occurs  very  early  in  embryonic  life  ; 
according  to  Dohm  it  is  completed  by  the  end  of  the  second  month.  From 
the  fact  of  this  identity  of  structure  there  naturally  exists  between  these 
organs  a  close  sympathy  in  health  and  disease. 

In  the  adult  woman,  according  to  Carl  Hennig,3  the  right  tube  is  nine 
and  a  half  centimetres  (three  and  three-fourths  inches),  while  the  left 
measures  only  eight  and  a  half.  The  abdominal  extremity  has  attached 
to  it  five  large  and  ten  small  fimbriae.  The  walls  of  these  tubes  consist : 
1st.  Of  peritoneum,  which  covers  them  to  the  fimbriated  extremities. 
2d.  Of  connective  tissue,  in  which  are  interspersed  two  sets  of  muscular 

1  Treatise  on  Human  Physiology,  by  J.  C.  Dalton,  p.  645. 

2  Prof.  Dohm,  of  Marburg.  Tran.sac.  Inabruck  Convention,  Obstet.  Journ.,  vol. 
iii.  ]>.  107. 

3  Uterine  Catarrb.     Translation  in  Obstet.  Journ.  vol.  iii.  p.  468. 


ANATOMY;.  761 

fibres,  external  or  longitudinal,  and  internal  or  transverse,  which  are  con- 
tinuations of  the  muscular  tissue  of  the  uterus  and  broad  ligaments.  At 
the  point  where  these  tubes  enter  the  uterus,  llennig  declares  that  the 
longitudinal  and  transverse  layers  of  fibres  both  become  greatly  developed, 
and  that  the  latter  forms  here  a  distinct  sphincter  tubce.  3d.  We  iind 
within  and  lining  the  tube  a  mucous  membrane,  which  is  thrown  into  large 
and  small  folds,  which  are  very  evident  near  the  fimbriated  extremity, 
and  gradually  become  insignificant  as  we  advance  towards  the  uterus. 
Within  this  membrane  Mr.  Bowman  discovered  tubal  glands,  which  consist 
of  grape-like  structures,  extending  downwards  towards  the  subjacent  mus- 
cular fibre.  They  differ  from  the  muciparous  follicles  of  the  vagina,  the 
Nabothian  glands  of  the  cervix,  and  from  the  utricular  follicles  of  the  ute- 
rine cavity.  Kolliker  denies  the  existence  of  these,  but  llennig1  describes 
them  very  fully.  These  compound  glands  of  the  Fallopian  tubes  are  lined 
with  an  epithelium  of  basement  form.  The  mucous  membrane  covering 
over  the  tubes,  and  not  dipping  down  into  these  glands,  is  covered  by  a 
ciliated  epithelium,  the  broom-like  action  of  which  is  exerted  towards  the 
uterus.  The  object  of  this  seems  to  be  to  sweep  the  products  of  the  ovaries 
into  the  uterus,  and  to  force  in  the  same  direction  menstrual  blood  oozing 
into  the  tubes  from  their  mucous  lining,  as  a  result  of  ovulation.  The 
zoosperms,  which  are  known  to  pass  through  the  uterus  and  proceed  as 
far  as  the  ovaries,  are  themselves  endowed  with  powerful  ciliary  action  in 
the  single  cilia  which  each  possesses,  and  by  this  they  overcome  the 
opposing  force  of  the  tubal  ciliaB. 

It  is  highly  probable,  to  say  the  least,  that  the  erectile  condition  induced 
in  the  mucous  membrane  of  the  uterus  and  tubes  by  contraction  of  the 
middle  coat  of  their  muscular  fibres  produces  in  the  latter,  as  in  the  for- 
mer, rupture  of  bloodvessels  and  consequent  hemorrhage.  Hennig  declares 
that  "during2  menstruation  throughout  its  entire  surface,  it  (the  mucous 
membrane  of  the  tubes)  assumes  a  dark  red  color."  Ruysch,  an  old 
anatomist  of  Amsterdam,  who  wrote  in  1737,  describes  a  post-mortem 
examination  in  which  he  discovered  the  Fallopian  tubes  containing  blood. 
This  has  by  some  of  the  writers  upon  the  history  of  hematocele  been  con- 
strued into  a  record  of  that  affection,  but  the  passage  appears  to  refer 
merely  to  a  condition  which  depends  upon  ovulation.  Messrs.  Bernutz 
and  Goupil3  mention  instances  of  the  collection  of  blood  in  the  Fallopian 
tubes  in  consequence  of  obstruction  of  these  canals.  Dr.  Duncan4  admits 
that  some  blood  may  come  from  the  tubes  in  natural  menstruation.  In 
two  of  my  cases  of  ovariotomy  in  which  I  employed  the  clamp,  the  pa- 
tients menstruated  regularly  through  the  tube  for  three  periods,  when  at 
the  same  time  menstruating  per  vaginam.     The  abdominal  opening  then 

1  Loc.  cit.,  p.  473.  2  Loc.  cit.,  p.  470. 

3  Op.  cit.,  vol.  i.  *  Fecundity,  Fertility,  and  Sterility,  p.  388. 


762  DISEASES    OF    THE    FALLOPIAN    TUBES. 

closed,  and  the  discharge  was  thereafter  confined  to  the  vagina.  Other 
cases  of  the  same  kind  are  on  record.  Now  as  in  these  cases  there  was 
free  exit  of  blood  per  vaginam,  there  can  be  no  reason  lor  believing  that 
a  regurgitant  action  occurred.  The  blood  flowing  by  the  tube  was  more 
probably  the  result  of  hemorrhage  into  that  canal,  the  uterine  end  of  which 
was  constricted  by  traction,  effected  by  the  confinement  of  the  abdominal 
end  in  the  wound. 

The  diseases  by  which  the  Fallopian  tubes  may  be  affected  are  the 
following : — 

Inflammation ; 
Stricture ; 
Distention ; 
Displacements. 

Inflammation  of  the  tubes,  or  salpingitis,  consists  in  inflammation  of 
their  mucous  membrane,  and  may  be  either  acute  or  chronic. 

The  acute  variety  generally  results  from  puerperal  endometritis,  or  from 
gonorrhoea,  which  has  extended  through  the  uterine  mucous  membrane. 
I  have  twice  seen  this  disease  almost  destroy  life  by  attacking  the  uterine 
mucous  membrane,  and  subsequently  producing  pelvic  peritonitis,  doubtless 
reaching  the  peritoneum  by  traversing  the  tubes. 

Chronic  salpingitis  is  one  of  the  sources  of  uterine  leucorrhoea,  and  com- 
monly produces  permanent  interference  with  the  calibre  of  the  tubes.  In 
some  cases  it  results  in  constrictions,  while  in  others  it  produces  dilatation. 
The  latter  condition  it  probably  is  which  produces  the  discrepancy  observed 
between  the  reports  of  various  observers  as  to  the  dangers  resulting  from 
intra-uterine  injections.  When  the  sphincteric  action  of  the  sphincter 
tubas  of  one  or  both  sides  is  destroyed,  fluid  thrown  into  the  uterus  will 
sometimes  enter  the  tubes,  and  produce  in  them  contraction,  spasm,  and 
violent  acute  salpingitis,  which  may  go  on  to  the  production  of  peritonitis 
and  death.  "When  dilatation  has  occurred  it  is  not  at  all  rare  for  the 
uterine  sound  to  be  passed  for  several  inches  up  the  tube.  I  have  met 
with  several  unquestionable  cases  of  this  kind.  I  say  unquestionable,  be- 
cause the  sound  must  have  followed  one  of  two  courses — through  the  fundus 
into  th«  peritoneum,  or  up  the  canal  of  one  of  the  tubes. 

As  this  subject  has  created  some  discussion,  I  will  rapidly  allude  to  two 
of  these  cases. 

A  physician,  residing  near  this  city,  wrote  to  me  concerning  the  case  of 
his  wife,  who  had  chronic  corporeal  endometritis  of  several  years'  duration. 
Upon  using  the  sound,  he  was  alarmed  at  finding  it  pass  into  the  uterus  nearly 
six  inches.  The  lady  came  down  to  me,  and  upon  repeated  measurement 
1  found  the  sound  pass  a  little  over  three  inches.  Th«  patient  went  home, 
and  her  husband,  surprised  at  my  results,  used  the  sound  again,  when, 
as  before  in  his  hands,  it  passed  in  over  five  inches.  To  solve  the  para- 
dox  he  at  once  came   down  with  her,  and  when  examining  with  him  I 


SALPINGITIS    AND    STRICTURE.  768 

distinctly  showed  him  the  normal  measurement,  a  little  over  three  inches, 
and  then  twice  passed  the  sound  up  one  tuhe  a  distance  of  two  inches. 

One  of  my  clinical  assistants  pointed  out  to  me  at  my  clinique,  as  a  fit 
subject  for  a  lecture,  a  patient  whose  uterus  measured  five  inches,  and  who 
presented  no  symptoms  except  those  of  ordinary  uterine  catarrh.  I  had 
occasion  to  examine  this  patient,  after  stating  this  measurement,  before 
the  class,  when  I  found  that  the  sound  passed  only  three  inches.  Confi- 
dent, from  the  well-known  accuracy  of  my  assistant,  that  he  could  not 
have  erred,  I  at  once  stated  to  the  class  what  I  believed  to  be  the  cause 
of  the  discrepancy,  and  in  its  presence  passed  the  probe  up  the  right  tuhe, 
making  a  measurement  of  five  inches.  To  avoid  all  chance  of  error,  I 
then  requested  my  assistant  to  verify  my  two  measurements,  when  he  also 
passed  it  first  three  inches  to  the  fundus  uteri,  then  two  inches  up  the 
right  tube.  Hildebrandt1  relates  two  cases  in  which  he  passed  a  prohe 
up  the  tuhe,  and  similar  instances  are  recorded  by  Veit,2  Matthews  Dun- 
can,3 Noeggerath,4  and  others. 

The  great  danger  in  both  acute  and  chronic  salpingitis  is  pelvic  perito- 
nitis, which  may  spread  and  destroy  life.  This  arises  in  part  from  escape 
of  the  contents  of  the  inflamed  tuhes  into  the  peritoneum. 

Of  the  symptoms  very  little  can  be  said.  The  chronic  variety  may 
continue  for  years,  and  result  in  dilatation  of  the  tuhe  with  no  symptoms 
which  arrest  attention ;  while  the  acute  form  so  quickly  produces  local 
peritonitis,  that  its  symptoms  are  lost  in  those  of  that  affection. 

No  special  treatment  is  applicable  to  it  except  the  adoption  of  means  to 
prevent  peritonitis,  as  rest,  opiates,  leeches,  and  strict  avoidance  of  sexual 
intercourse. 

The  great  obscurity  of  the  diagnosis  of  tubal  diseases  renders  the  sub- 
ject one  upon  which  it  is  not  profitable  to  speak  further,  although  as  a 
pathological  study  it  is  one  of  great  interest. 

Stricture — The  Fallopian  tubes,  which  are  often  imperfect  or  wanting 
when  the  uterus  is  absent  or  undeveloped,  may,  even  after  full  develop- 
ment, be  affected  by  stricture.  The  condition  may  be  produced  by  these 
causes : — 

Calcific  deposit ; 
Senile  atrophy ; 
Salpingitis  ; 
Pelvic  peritonitis  ; 
Tuhercle  or  fibrous  tumors. 

Partial  obliteration  of  the  canal  results  in  sterility  if  it  affect  both  sides 
simultaneously,  and  sometimes,  by  causing  the  accumulation  of  fluids,  it 

1  Barnes's  Report  on  Midwifery,  Brit,  and  For.  Med.-Cliir.  Review,  Oct.  1868. 

2  New  York  Obstet.  Journ.,  vol.  i.  p.  267. 

3  Edinburgh  Med.  Journ.,  1856. 

4  Remarks  before  Obstetrical  Society,  New  York. 


TG4 


DISEASES    OF    THE    FALLOPIAN    TUBES. 


produces  tubal  dropsy.  It  is  not  rare  for  rupture  of  the  tubes  and  conse- 
quent hematocele  and  peritonitis  to  result  from  imprisonment  of  menstrual 
fluid  in  them.  M.  Puech  analyzed  two  hundred  and  fifty-eight  cases  of 
congenital  atresia  of  the  genital  organs,  and  found  that  in  fifteen  cases  the 
Fallopian  tubes  were  dilated,  and  in  five  were  ruptured.  The  condition 
is  rather  a  study  for  the  pathological  anatomist  than  for  the  gynecologist, 
for  it  can  neither  be  diagnosticated  nor  relieved  by  treatment. 

Distention The  tubes  may  be  distended  by  accumulation  of  mucus, 

pus,  menstrual  blood,  or  a  muco-serous  material  secreted  by  the  altered 
mucous  membrane  accompanying  great  and  prolonged  distention.  This 
condition  invariably  has  as  its  moving  cause  stricture,  which  prevents  the 
tube  from  emptying  itself  into  the  uterus.  When  very  great  distention 
takes  place,  the  accumulated  fluid  either  forces  its  way  out  of  the  uterine 
extremity,  constituting  the  profluent  dropsy  of  Rokitansky,  or  passes  out 
of  the  fimbriated  extremity  into  the  peritoneum,  or  a  rupture  of  the  tube 
occurs.  Such  an  accumulation  may  produce  a  tumor  equal  in  size  to  the 
head  of  a  child  of  ten  years,  and  some  say  even  much  larger,  though  theio 
is  doubt  as  to  the  authenticity  of  the  latter  cases.  Virchow  has  established 
a  class  of  cysts  which  he  styles  cysts  from  retention,  to  which  distention  of 
the  tube  by  sero-mucus  properly  belongs. 

Fig.  266. 


Tubal  dropsy.     (Boiviu  aud  Dugds.) 


The  diagnosis  in  advanced  cases,  where,  for  example,  the  tumor  lias 
developed  to  the  extent  just  mentioned,  is  difficult  and  often  impossible. 
Sometimes,  however,  it  may  be  made  by  the  following  means :  An  elon- 
gated,  fluctuating,  movable  tumor  is  felt  in  the  retro-uterine  space  a  little 
to  one  side  ;  in  its  outlines  the  tumor  is  wavy,  and  it  can  be  separated 
from  the  uterus.  Scanzoni  quotes  Kiwisch  as  declaring  that,  in  such  cases, 
the  presence  at  the  side  of  the  fundus  of  a  mammillated,  elastic,  and 


EXTRA-UTERINE    PREGNANCY.  705 

elongated  tumor,  justifies  the  diagnosis  of  tubal  dropsy,  but  he  differs  from 
him,  and  regards  the  positive  diagnosis  as  impossible.  In  case  the  diag- 
nosis can  be  arrived  at,  the  most  appropriate  treatment  would  consist  in 
tapping  per  vaginam. 

Displacements The  tubes  may  pass  with  hernial  protrusions  into  the 

inguinal  or  crural  openings,  and,  in  case  of  inversion  of  the  uterus,  may 
descend  into  the  cavity  of  the  displaced  organ.  It  is  generally  in  com- 
pany with  the  ovary  that  the  tube  leaves  its  place,  but  at  times  it  descends 
alone.  Dr.  Scholler1  reports  an  instance  in  which,  in  a  child  who  died 
twenty  days  after  birth,  a  tumor  was  discovered  which  extended  from  the 
inguinal  region  to  the  right  labium,  and  contained  the  Fallopian  tube, 
which  was  non-adherent.  A  crural  hernia  of  the  tube  alone  which  ended 
fatally  is  likewise  recorded  by  M.  Berard. 

Prof.  Rokitansky,2  and  Dr.  Turner,  of  Scotland,  have  both  drawn 
attention  to  severance  of  the  tube  from  the  ovary  by  traction  from  in- 
creased weight  of  the  latter  or  from  false  membranes.  The  former  cites 
twelve  instances  in  support  of  the  fact. 

Other  Diseases  of  the  Tubes In  addition  to  these  diseases  the  tubes 

are  sometimes  affected  by  cancer,  tubercle,  fibrous  tumors,  abscess,  and 
accumulation  of  blood  in  their  canals  from  hemorrhage  from  the  mucous 
membrane.  There  is  so  strong  an  analogy  between  these  disorders  and 
the  same  in  other  organs,  that  it  is  not  deemed  necessary  to  enter  upon 
their  consideration. 


CHAPTER  LII. 

EXTRA-UTERINE  PREGNANCY. 

It  is  evident  that  to  condense  into  the  narrow  limits  of  a  short  chapter 
a  subject  which  would  require  a  volume  for  its  extended  consideration, 
involves  of  necessity  a  superficial  review  of  its  essential  points  only. 

It  may  even  be  thought  by  some  that  this  subject  is  out  of  place  in  a 
work  upon  gynecology,  and  that  it  should  have  been  left  for  one  devoted 
to  obstetrics.  Its  admission  here  is  proof  of  the  fact  that  I  do  not  share 
this  feeling.  Ectopic  gestation,  although  theoretically  falling  in  the  domain 
of  the  obstetrician,  in  reality  almost  always  claims  the  attention  of  the 
gynecologist  from  the  fact  that  the  existence  of  pregnancy  is  in  these  cases 
very  generally  not  recognized,  the  patient  being  supposed  to  suffer  from 
some  pelvic  tumor  or  obscure  uterine  or  ovarian  disorder.  It  is  very 
frequently  necessary  to  differentiate  it  from  a  variety  of  disorders  which 

1  Courty,  op.  cit.  8  Sydenham  Soc.  Year-Book,  1861. 


766  EXTRA-UTERINE    PREGNANCY. 

will  soon  be  mentioned,  and  even  its  treatment  involves  rather  a  familiarity 
with  the  resources  of  gynecology  than  witli  those  of  obstetrics. 

Definition  and  Synonyms Extra-uterine  pregnancy,  extra-uterine  or 

ectopic  gestation  signifies  the  fixation  and  development  of  the  impregnated 
ovum  outside  of  the  uterine  cavity. 

Varieties. — For  the  physiologist  and  pathologist  there  are  many  varieties 
of  this  abnormal  gestation  ;  for  the  gynecologist  there  are  but  three. 
For  him  the  tubo-ovarian,  tubo-abdominal,  ovarian,  and  some  other 
varieties  are  niceties  beyond  the  appreciation  of  diagnosis,  and  he  is  forced 
to  limit  himself  as  far  as  practice  is  concerned  to  the  classification  of  all 
varieties  into,  1st,  tubal ;  2d,  interstitial ;  and  3d,  abdominal  pregnancies. 
These  by  rational  and  physical  signs  he  may  differentiate  from  each  other, 
and  in  certain  cases  base  the  propriety  of  surgical  interference  upon  his 
conclusions.  These,  and  these  only,  then,  are  the  varieties  which  we  shall 
consider  in  this  chapter. 

Tubal  pregnancy,  the  most  dangerous  of  all  varieties  of  extra- uterine 
gestation,  consists  in  the  arrest  of  the  impregnated  ovum  in  the  Fallopian 
tube  and  its  development  there.  It  may  be  that  instead  of  being  abso- 
lutely in  the  tube  the  fructified  ovum  may  develop  just  where  the  fimbri- 
ated end  of  the  tube  clasps  the  ovary. 

Interstitial  pregnancy  consists  in  an  advance  of  the  ovum  through  the 
tube  until  it  begins  to  pass  through  the  uterine  wall.  Then  an  arrest 
taking  place  before  the  ovum  enters  the  uterus,  it  attaches  itself,  distends 
the  parenchyma  of  the  uterus  to  make  its  nidus,  and  causes  it  to  protrude 
partly  towards  the  uterine  cavity,  partly  towards  the  abdominal. 

In  abdominal  pregnancy  one  of  two  things  occurs :  either  the  tube 
holding  the  impregnated  ovum  in  its  grasp  breaks  away  from  its  ovarian 
attachment,  falls  into  the  abdominal  cavity,  and  remains  there,  while  the 
ovum  casting  out  tentacula  attaches  itself  to  the  peritoneum  and  grows ; 
or,  as  some  suppose  possible,  the  impregnated  egg  falls  out  of  the  grasp  of 
the  tube,  and,  getting  its  nourishment  from  the  peritoneum,  develops  in- 
dependently of  the  lining  membrane  of  the  uterus  which  extends  through- 
out the  tubes. 

Etiology. — It  is  a  fact  universally  accepted  that  in  the  human  female,  as 
in  the  lower  order  of  animals,  impregnation  of  the  ovule  often  occurs  at  or 
near  the  ovary.  In  some  cases,  by  a  stricture  in  the  tube,  due  to  lessening 
of  its  calibre  by  inflammation,  the  development  of  a  little  tumor,  or  con- 
traction of  lymph  poured  out  by  pelvic  peritonitis,  an  obstruction  is  offered 
to  the  progress  of  the  ovum  towards  the  uterus.  In  contact  with  a  mucous 
membrane  closely  resembling  that  of  the  uterus,  it  at  once  accommodates 
itself  to  its  vicarious  quarters,  attaches  itself,  forms  a  placenta,  and 
steadily  grows.  There  are  many  points  in  pathology  concerning  which 
no  one  has  a  right  to  an  opinion  who  has  not  made  researches  of  a  more 
or  less  personal  character  in  regard  to  them.     The  pathology  of  extra- 


PATHOLOGY.  767 

uterine  pregnancy  is  one  of  them,  and  although  my  experience  in  refer- 
ence to  this  condition  is  quite  large,  as  I  shall  soon  show,  I  express  myself 
upon  it  with  great  hesitation. 

Although  extra-uterine  gestation  has  been  divided  by  pathologists  into 
abdominal,  tubal,  ovarian,  interstitial,  tubo-abdominal,  and  tubo-ovarian, 
it  seems  highly  improbable  that  the  ovum  at  the  moment  of  its  impregna- 
tion could  attach  itself  to  any  other  tissue  than  the  lining  membrane  of 
the  uterus,  which  is  so  especially  constructed  to  accommodate  it.  Once 
having  undergone  development  in  this  connection,  however,  it  rapidly 
invades  adjoining  structures,  the  omentum,  peritoneum,  etc.,  and  forces 
them  to  nourish  it. 

Pathology Should  the  arrest  of  the  ovum  have  occurred  in  one  of  the 

tubes,  it  develops  rapidly  and  endeavors  to  furnish  a  uterus  for  the  grow- 
ing child.  But  the  muscular  structure  of  the  tubes,  being  scanty  compared 
with  that  of  the  uterus,  although  it  develops  to  accommodate  its  contents, 
gradually  grows  thinner  and  thinner  under  distention  until,  towards  the 
end  of  the  first,  second,  or  third  month,  it  usually  ruptures,  and  the  con- 
tents of  the  ovum,  as  well  as  much  blood  escaping  from  the  ruptured  ves- 
sels of  the  tube,  escape  into  the  peritoneal  cavity. 

A  true  hematocele  is  thus  created,  the  patient  generally  becoming  col- 
lapsed, and  dying,  and  very  rarely  escaping  by  absorption  of  the  blood 
and  by  encapsulation  or  discharge  of  the  foetus.  Veit1  declares  that  about 
one-fifth  of  all  cases  of  hematocele  are  due  to  the  rupture  of  tubal  preg- 
nancies, and  that  recoveries  occur  under  these  circumstances  much  more 
commonly  than  is  generally  supposed.  I  do  not  agree  with  him  as  to 
the  frequency  of  this  cause  of  hematocele,  but  I  am  quite  sure  that  I 
have  seen  it  thus  produced,  and  have  seen  recovery  follow.  These  are 
the  cases  of  hematocele  which  are  classed  by  Barnes  under  the  name 
of  "cataclysmic."  As  a  rule  the  violence  of  their  onset  entitles  them  to 
that  name,  but  it  is  highly  probable  that  some  of  those  occurring  at  early 
periods  of  gestation  develop  with  less  violent  and  overwhelming  symp- 
toms. 

Hecker  reports  45  cases  of  tubal  pregnancy.  In  26  cases  rupture  oc- 
curred in  the  first  month,  in  11  cases  in  the  third  month,  in  7  cases  in  the 
fourth,  and  once  in  the  fifth  month.  Spiegelberg"  reports  a  case  of  an 
ovum  advancing  to  maturity  in  the  tube. 

Interstitial  pregnancy  is  much  less  frequent  and  less  dangerous  than  the 
variety  just  mentioned.  It  is  much  more  likely  to  advance  to  full  term, 
and  while  it  may  produce  death  by  rupture  and  discharge  into  the  perito- 
neum, it  may,  as  in  my  fourteenth  case,  discharge  into  the  uterus  and  be 
expelled  through  the  natural  passages.  Dr.  Lenox  Hodge  once  succeeded 
in  recognizing  the  existence  of  such  a  case  at  full  term,  cut  through  the 

1  Deutsche  Zeit.  fur  prakt.  Med.,  No.  49,  1878. 
*  Arch.  f.  Gyn.,  Bd.  i.  p.  406. 


768  EXTRA-UTERINE    PREQNANCY. 

layer  of  parenchyma  which  shut  the  foetus  off  from  the  uterus,  and  con- 
ducted the  case  to  a  successful  issue. 

Although  not  attended  by  as  great  dangers  as  attach  to  tubal  and  in- 
terstitial pregnancies,  the  abdominal  variety  is  a  most  serious  aberration 
from  normal  gestation,  and  one  which  commonly  destroys  life.  In  the 
first  two  forms  the  rapidly  developing  ovum  is  imprisoned  in  tissues  which 
are  inapt  for  great  distention,  and  which  rupture  under  its  influence.  In 
the  third  the  foetal  ball  has  at  its  disposal  for  expansion  and  growth  the 
whole  peritoneal  cavity,  the  placenta  encroaching  in  its  search  after  nu- 
triment upon  the  bladder,  the  omentum,  the  intestines,  and  any  portion  of 
the  peritoneum  within  its  reach.  The  events  of  this  form  of  pregnancy 
are  the  following:  First,  the  foetus  unnaturally  attached  and  nourished 
may  die  in  the  early  months  of  its  life,  become  encysted,  and  in  time  be 
cast  off  through  the  rectum,  the  bladder,  or  through  the  abdominal  walls. 
Second,  the  pregnancy  may  advance  to  the  end  of  the  ninth  month,  when, 
labor  coming  on,  nature  makes  a  persistent  effort  to  expel  the  child,  but, 
on  account  of  there  being  no  way  of  exit,  fails,  and  the  child,  with  its  en- 
velopes, is  retained,  and  becoming  encysted  remains  in  its  nidus  for  years, 
creating  no  disturbance  by  its  presence.  Third,  the  child,  shut  up  in  its 
unopened  shell,  acts  as  a  foreign  body,  creates  suppurative  action  in  its 
envelopes,  and  becomes  surrounded  with  pus  in  place  of  liquor  amnii.  Or, 
the  liquor  amnii  being  absorbed,  the  fcetal  bones  become  closely  hugged 
by  the  walls  of  the  cavity  which  contains  them,  and  act  as  an  intense 
irritant,  which  sets  up  formation  of  pus  and  in  this  way  leads  to  hectic 
fever  from  absorption  of  septic  material. 

Hecker  found  that  out  of  132  cases  of  abdominal  pregnancy,  76  termi- 
nated in  recovery.  Recovery  took  place  in  28  cases  after  expulsion  of 
foetus  per  anum,  in  17  cases  after  formation  of  lithopaedion,  in  15  cases 
after  elimination  through  the  abdominal  wall,  in  11  cases  after  laparotomy, 
in  3  cases  following  vaginal  section,  in  2  cases  from  undefined  causes. 
Death  followed  from  hectic  in  18  cases,  peritonitis  in  12  cases,  operations 
in  12  cases,  rupture  and  hemorrhage  in  7  cases,  fecal  vomiting  in  2  cases, 
dropsy  in  1  case,  cause  not  defined  in  4  cases. 

Causes  of  Death The  causes  of  death  in  the  various  forms  of  extra- 
uterine pregnancy  may  thus  be  presented: — 

Shock  ; 

Hemorrhage ; 

Septicaemia  ; 

Peritonitip  ; 

Hectic  fever ; 

Perforation  of  important  viscera  by  bones. 
Symptoms.- — The  suspicion  of  extra-uterine  pregnancy  is  usually  created 
in  one  of  the  following  ways:    1st.  A  woman  who  has  passed  over  one, 
two,  or  three  menstrual  epochs  is  suddenly  seized  with  the  symptoms  of 


SYMPTOMS — DIFFERENTIATION.  769 

hematocele,  agonizing  pelvic  pain,  faintness,  coldness  of  extremities, 
bathing  of  face  with  cold  sweat,  rapid  and  feeble  heart  action,  and  nausea 
and  retching.  She  dies  of  overwhelming  nervous  paresis,  called  "  shock," 
of  hemorrhage,  of  peritonitis,  or  of  septicaemia  ;  or  she  gets  well,  the  diag- 
nosis of  pregnancy  is  regarded  as  a  mistake,  and  she  is  said  to  have  re- 
covered from  hematocele  which  was  the  result  of  temporary  suppression  of 
menstruation. 

2d.  A  woman  who  supposes  herself  to  be  pregnant  becomes  alarmed  by 
the  development  of  one,  two,  or  three  sets  of  abnormal  symptoms  :  (a) 
the  occurrence  of  irregular,  immoderate,  sudden,  and  excessive  gushes  of 
blood  ;  (b)  the  rapid  and  disproportionate  enlargement  of  the  hypogas- 
trium  ;  or  (c)  the  manifestation  of  a  dull,  grinding  pain,  fixed  in  one  iliac 
fossa  or  extending  thence  down  the  thighs,  and,  as  time  passes,  becoming 
markedly  paroxysmal  and  spasmodic. 

Suspicion  is  thus  excited,  not  of  the  existence  of  this  vice  of  gestation, 
but  of  something  being  wrong,  and  a  careful  examination  by  rational  and 
physical  signs  is  instituted.  Should  such  examination  be  made  after  rup- 
ture of  the  vicarious  uterus,  and  escape  of  its  contents  into  the  peritoneal 
cavity,  the  ordinary  physical  signs  of  hematocele  will  be  detected,  and  to 
their  enumeration  in  the  chapter  devoted  to  that  subject  the  reader  is  re- 
ferred. 

Physical  Signs Besides  the  symptoms  mentioned  pointing  to  the  advi- 
sability of  a  physical  examination,  the  uterus  is  usually  found  enlarged, 
lifted  up  in  the  pelvis,  and  pressed  forwards  or  laterally  by  a  tumor  which 
exists  posterior  to  it  or  on  one  side.  This  tumor  is  found  to  be  nearly 
immovable,  very  slightly  sensitive  upon  pressure,  and  marked  by  a  peculiar 
degree  of  hyperemia,  which  gives,  to  an  exaggerated  degree,  the  violet 
hue  of  gestation  to  the  vagina.  It  is  marked  by  a  very  rapid  growth,  so 
that  a  week's  watching  will  show  a  decided  increase  in  its  dimensions. 

The  tumor  alone  would  not  furnish  sufficient  grounds  upon  which  to 
found  a  diagnosis  of  ectopic  gestation,  but  a  rapidly  growing  pelvic  tumor 
accompanied  (a)  by  the  gastric  and  mammary  symptoms  of  pregnancy, 
(b)  by  cessation  of  menstruation,  (c)  by  enlargement  of  the  uterus,  (d)  by 
the  purple  hue  of  the  vagina,  and  (e)  by  the  detection  of  ballottement  in 
the  tumor,  would  do  so. 

Differentiation The  conditions  with  which  extra-uterine  gestation  is 

most  likely  to  be  confounded  are  the  following : — 
Uterine  fibroma  or  fibro-cyst ; 
Cyst  of  ovary  or  broad  ligament ; 
Hematocele  ; 

Double  or  bi-corned  uterus  with  impregnation  of  one  side. 
Normal  pregnancy  with  retroflexion  ; 
Pelvic  abscess. 

The  uterus  is,  in  these  cases,  lined  by  decidua,  and  it  is  almost  as  much 
49 


770  EXTRA-UTERINE    PREGNANCY. 

enlarged  as  in  normal  pregnancy.  Before  any  decision  is  arrived  at  it  is 
often  wise  to  dilate  the  cervical  canal  with  tents,  so  that  the  finger  may 
be  introduced  to  the  fundus.  By  this  measure  normal  pregnancy,  if  it 
exist,  is  interfered  with,  but  the  exigency  requiring  immediate  diagnosis  is 
so  great,  that  this  disadvantage  must  be  accepted. 

Dilatation  of  the  cervical  canal  having  served  to  exclude  normal  preg- 
nancy, while  all  the  symptoms  of  pregnancy  exist  with  marked  enlarge- 
ment and  softening  of  the  uterus,  and  with  the  presence  of  a  suspicious 
tumour  in  the  pelvis,  the  probabilities  in  favor  of  extra-uterine  foetation 
become  strengthened.  Still  the  differentiation  of  this  from  the  other 
conditions  mentioned  remains  to  be  established,  and  it  is  often  very 
difficult.  It  is  only  by  the  most  careful  consideration,  patient  research, 
and  judicious  delay  that  it  can  usually  be  accomplished.  While  these  are 
being  exercised,  rupture  of  an  extra-uterine  foetal  nest  may  occur,  and  a 
fatal  issue  be  the  consequence. 

In  some  cases,  ballottement,  clear  and  distinct  as  that  which  is  gotten  in 
normal  pregnancy,  lends  us  its  aid  and  makes  diagnosis  certain  ;  in  others 
the  aspirator  clears  up  the  case ;  while  in  others  still,  where,  for  example, 
the  question  lies  between  a  cyst  of  the  broad  ligament  and  extra-uterine 
pregnancy,  cutting  into  the  sac  by  means  of  the  incandescent  knife  will 
combine  diagnosis  and  treatment  in  a  most  satisfactory  manner. 

Let  me  illustrate  the  difficulties  and  methods  of  diagnosis  under  these 
circumstances  by  the  relation  of  three  cases. 

Case  1. — Mrs.  A.  suddenly  ceased  menstruating,  and  for  three  months 
suffered  from  nausea  and  vomiting,  and  pelvic  pain  extending  down  one 
thigh,  and  became  so  enfeebled  and  emaciated  that  she  could  not  stand  with- 
out support.  She  came  to  me  from  Peekskill,  and  upon  examination  I  found 
the  uterus  elevated  and  pushed  to  one  side  by  a  fluctuating  tumor  in  one 
iliac  fossa.  Drs.  Fordyce  Barker  and  Noeggerath  saw  her  in  consultation 
with  me,  and  we  could  not  decide  whether  it  was  a  case  of  amenorrhoea 
with  cyst  of  the  broad  ligament  or  tubal  pregnancy.  Immediate  action 
was  necessary,  and  I  cut  through  the  vaginal  walls  with  Paquelin's  thermo- 
cautery and  found  the  former  condition  existing. 

Case  2 Mrs.  B.  was  brought  to  Dr.  Marion  Sims  and  myself  to  de- 
cide as  to  the  cause  of  irregular  menses,  with  violent  pain  in  left  iliac 
fossa.  Physical  examination  showed  uterus  pushed  upwards  and  laterally 
by  a  tumor  attached  to  its  left  horn.  The  question  lay  between  intersti- 
tial pregnancy  and  inflammatory  product  in  left  broad  ligament.  To 
decide  it  we  fully  dilated  the  uterus  by  tents,  introduced  the  finger  fully 
to  the  fundus,  and  found  the  latter  condition  to  exist. 

Case  3 Mrs.  C.  consulted  me  on  account  of  a  soft,  fluctuating  tumor 

posterior  to  the  uterus,  accompanied  by  cessation  of  menstruation.  I  was 
doubtful  whether  it  was  a  fixed  ovarian  cyst,  a  hematoma,  or  an  abdomi- 
nal pregnancy.     Her  symptoms  were  so  urgent  that  I  dared  not  delay  for 


RECOGNITION    OF    THE    VARIETIES.  771 

time  to  solve  the  question,  so  I  passed  through  the  mass  a  strong  inter- 
rupted current  which  would  have  killed  a  foetus  had  one  existed.  But  it 
proved  to  be  a  hematoma,  and  was  subsequently  discharged  through  the 
rectum. 

The  question  of  diagnosis  being  a  very  momentous  one,  it  is  generally 
advisable  to  settle  it  by  crucial  tests,  which  are  not  attended  by  great  dan- 
ger if  the  case  be  not  one  of  pregnancy,  and  might  prove  curative  if  it 
were  so. 

Very  often  we  hear  of  physicians  being  blamed  on  account  of  failure  of 
diagnosis  in  these  cases  which  suddenly  die  from  rupture.  Every  medical 
man  who  countenances  such  a  charge  demonstrates  his  want  of  experience 
or  his  want  of  professional  loyalty  by  so  doing.  Very  often  there  is 
nothing  in  these  terrible  cases  to^excite  suspicion;  very  generally  nothing 
to  decide  us  positively  even  when  suspicion  is  excited. 

Symptoms  of  Approaching  Rupture. — The  part  containing  the  foetus 
and  constituting  a  vicarious  uterus  begins  to  contract,  and  miniature  uterine 
efforts  show  themselves  in  increasing  severity,  a  bloody  flow  takes  place 
from  the  cervix,  and  very  commonly  a  small  piece  of  deciduous  membrane 
is  expelled.  These  symptoms  will  very  probably  be  supposed  to  point  to 
abortion,  and  the  case  is  usually  allowed  to  proceed  until  the  suddenly  de- 
veloped symptoms  of  rupture  of  the  sac  serve  to  open  the  eyes  of  the  prac- 
titioner to  the  truth,  or  at  least  excite  in  his  mind  a  strong  suspicion  of  it. 

Recognition  of  the  Varieties Nothing  is  easier  in  a  written  descrip- 
tion or  in  the  lecture-room  than  to  point  out  the  means  of  differentiating 
the  three  great  varieties  of  ectopic  gestation — abdominal,  interstitial,  and 
tubal.  Nothing  is  more  difficult,  as  every  man  of  large  experience  in  this 
difficulty  will  agree,  than  to  do  this  at  the  bedside.  In  general  terms  it 
may  be  said  that  the  interstitial  form  is  very  rare,  that  the  tumor  consists 
of  an  irregular  enlargement  of  the  uterine  body,  and  that  the  tumor  moves 
with  the  uterus,  while  at  the  same  time  this  organ  is  empty :  that  tubal 
pregnancy  gives  an  enlargement  at  the  side  of  the  uterus,  yields  ballotte- 
ment  more  generally  than  the  other  forms,  and  is  marked  by  a  tumor 
somewhat  separated  from  the  uterus,  and  which  does  not  decidedly  move 
with  it :  and  that  abdominal  pregnancy  is  generally  detected  late,  at  a 
period  when  the  rolling  of  the  child's  body  in  the  abdomen  can  be  detected, 
while  at  the  same  time  the  uterus  is  found  to  be  empty. 

I  do  not  pretend  to  offer  these  differences  between  the  varieties  as  uni- 
versal and  reliable  means  of  differentiation.  Indeed,  no  such  means  will 
be  offered  by  any  one  whose  experience  is  large;  for  such  experience 
must  have  taught  him  that  none  such  exist.  I  have  seen  two  cases  of  in- 
terstitial pregnancy,  and  have  relied  in  the  description  which  I  have  given 
very  largely  upon  the  signs  presented  in  these. 

Prognosis. — Whatever  be  the  variety,  the  period,  or  the  circumstances 
connected  with  this  vice  of  gestation,  the  prognosis  is  bad.     True  a  large 


772 


EXTRA-UTERINE    PREGNANCY. 


number  of  women  escape  death ;  but  this  fact  does  not  contradict  the  state- 
ment just  made.  The  prognosis  is  most  favorable  in  abdominal  pregnancy 
when  adhesion  has  occurred  from  death  of  the  foetus  and  subsequent  in- 
flammation between  the  sac  wall  and  the  parietal  peritoneum ;  less  favor- 
able where  no  such  adhesion  exists  and  the  peritoneal  cavity  is  free  in 
front  of  the  foetal  shell.  It  is  more  favorable  in  interstitial  than  in  tubal 
pregnancy,  and  least  favorable  in  the  purely  tubal  variety.  In  the  tubal 
form  it  is  much  less  favorable  if  the  foetus  be  living  than  if  it  be  dead. 
Kiwisch1  reported  100  cases  of  extra-uterine  pregnancies,  with  18  re- 
coveries ;  Puech  100  cases  of  tubal  pregnancy,  98  cases  of  rupture  of  tube, 
2  of  rupture  of  vein  of  broad  ligament,  1  recovery;  199  cases  of  elimina- 
tion of  foetus  in  the  ovarian  and  abdominal  form,  146  recoveries.  (See 
Courty,  p.  996.) 

As  my  experience  in  this  condition  has  been  quite  large,  I  report  it  in 
full  in  the  subjoined  table : — 


o    • 

85  t 

With  whom  seen. 

Variety. 

Remedial  measures 
adopted. 

Termination. 

1 

Dr.  Mouraille. 

Tubal. 

Death  from  rupture. 

2 

Dr.  Henschel. 

Tubal. 

Aspiration   by   Dr. 
Thomas. 

Death  from  septicae- 
mia. 

3 

Dr.  Henschel. 
Dr.  Giberson. 
Dr.  J.  L.  Brown. 

Tubal. 
Tubal. 
Tubal. 

Death  from  rupture. 
Death  from  rupture. 
Death  from  rupture. 

4 

5 

Aspiration   by   Dr. 
Thomas. 

6 

Drs.  Green  and 
Crane. 

Tubal. 

Elytrotomy   by   Dr. 
Thomas  by  galvano 
caustic  knife  and  de- 
livery of  foetus. 

Recovery. 

7 

Drs.  Coates  and 
Barker. 

Abdominal. 

Laparotomy    by   Dr. 
Thomas. 

Recovery. 

8 

Dr.  Chas.  Young. 

Abdominal. 

Laparotomy   by   Dr. 
Thomas. 

Recovery. 

9 

Dr.  J.  Hadden. 

Abdominal. 

Laparotomy   by   Dr. 
Thomas. 

Recovery. 

10 

W.  J.  Walker. 

Abdominal. 

Discharged    by   vagi- 

Recovery. 

11 

12 

Olcott. 

Drs.    Barker, 
Fisher,  Lusk 

Abdominal. 
Tubal. 

Discharged  by  rectum. 

Recovery. 

Death  from  rupture. 

and  Metcalfe. 

13 

Dr.  Green. 

Interstitial. 

Died    years   after- 
wards  from   pneu- 

monia. 

14     Drs.  Emmet  and 

Interstitial. 

Life  of  foetus  destroyed 

Recovery. 

McBurney. 

by  electric  current ; 
foetus     discharged 

15     Drs.  Peaslee  and 

Abdominal. 

through  uterus. 
Incision  by  Dr.  Peas- 

Death from  septicae- 

Janvrin. 

lee. 

mia. 

1(3     Dr.  W.  Frankel. 

Abdominal. 
Abdominal. 

Still  living. 
Patient  living. 

17     Dr.  Harrison. 

Electric   current   now 

being  used. 

1  Spiegelberg,  Lehrbuch  der  Geb.  Hulfe,  1877,  p.  323. 


TREATMENT.  .    773 

Of  these  17  cases,  2  were  interstitial  and  both  recovered;  7  were  tubal 
and  1  only  recovered;  8  were  abdominal  and  5  recovered;  while  2  are  still 
doubtful.  Out  of  the  17  cases,  10  recovered  and  7  died.  This  fact,  how- 
ever, must  be  noted:  2  patients  still  live,  and  the  diagnosis  may  be  in- 
correct in  their  cases,  or  they  may  yet  die  of  the  condition  if  the  diagnosis 
be  correct.  Out  of  the  17  women  thus  affected,  9  were  submitted  to  sur- 
gical procedures,  and  out  of  these  G  recovered  and  3  died. 

Treatment. — In  dealing  with  the  treatment  of  extra-uterine  gestation, 
I  am  possessed  by  a  strong  desire  to  avoid  even  the  appearance  of  dogma- 
tism. There  is  none  in  the  whole  list  of  subjects  obstetrical  and  gyne- 
cological about  which  so  little  is  absolutely  settled  and  upon  which  prac- 
tical men  differ  so  widely.  At  one  extreme  stand  able  and  conservative 
practitioners,  who  appear  to  favor  the  position  that,  as  a  very  general  rule, 
we  should  stand  calmly  by  with  folded  arms  and  accept  without  effort  or 
resistance  the  terrible  chances  of  death  which  attend  these  cases.  At 
the  other,  we  see  enthusiastic  ones  with  strong  surgical  proclivities,  who 
would  apparently  resort  to  laparotomy  in  every  case  in  which  diagnosis 
is  possible.  On  a  middle  ground,  one  lying  between  these  extremes,  the 
truly  conservative  surgeon  will  find  his  appropriate  position. 

Let  us  in  the  beginning  recognize  the  fact  that,  do  what  we  will — re- 
main utterly  inactive,  or  use  the  greatest  surgical  enterprise — the  issue  of 
these  unfortunate  cases  will  very  likely  be  bad.  And  let  every  surgeon 
be  sure  that  he  does  not  shirk  a  dangerous  operation  because  he  fears  the 
odium  which  will  probably  attach  to  a  fatal  result,  and  which  he  would 
avoid  if  he  simply  allowed  his  patient  to  die  without  an  effort. 

He  who  cannot  bear  unjust  censure  and  endure  without  complaint  an 
odium  which  he  does  not  deserve,  was  not  born  to  be  a  surgeon,  one  of 
the  greatest  functions  of  whose  life  this  is ;  and  under  the  grave  responsi- 
bilities which  attach  to  the  conduct  of  a  case  of  ectopic  gestation  it  is  the 
bounden  duty  of  such  an  one  to  place  his  patient's  interests  in  stronger 
hands.  The  statement  is  true  everywhere  in  surgery,  but  nowhere  is  its 
truth  more  strikingly  apparent  than  in  these  cases,  that  every  personal 
consideration,  every  private  interest,  should  yield  to  the  good  of  the 
patient ! 

One  point  which  may  be  regarded  as  entirely  settled  in  the  treatment 
of  extra-uterine  pregnancy  is  this  :  a  secondary  operation  for  discharge  of 
the  contents  of  the  foetal  sac  is  always  safer  than  a  primary  one.  But  its 
antithesis  must  likewise  be  recognized — it  may  become  hazardous  to  dis- 
card a  primary  operation  and  to  expose  a  patient  to  the  delay  involved  by 
waiting  for  a  secondary  one.  The  rule  for  interference  should  then  be 
this  :  delay  is  wise  so  long  as  it  is  the  offspring  of  prudence  ;  it  is  culpable 
as  soon  as  it  becomes  the  dictate  of  timidity  and  indecision.  " 

The  only  way  in  which  justice  can  be  done  to  this  subject  is  by  supposing 


774  EXTRA-UTERINE    PREGNANCY. 

certain  conditions  differing  widely  from  each  other,  in  which  the  patient 
may  be  seen  : — 

(a)  The  tumor  being  low  in  the  pelvis,  fluctuation  distinct,  and  the 
diagnosis  of  extra-uterine  pregnancy  well  established,  the  life  of  the  foetus 
should  be  destroyed  by  means  as  certain  and  as  free  from  danger  as  possible. 
There  are  three  methods  by  which  this  may  be  done :  1st,  by  passing 
through  the  tumor  a  strong,  interrupted  current,  one  electrode  in  the 
rectum  and  the  other  on  the  most  prominent  part  of  the  tumor,  the  judg- 
ment of  the  practitioner  being  the  guide  as  to  the  power  and  duration  of 
the  current ;  2d,  by  injecting  through  the  vaginal  or  abdominal  walls,  by 
means  of  a  long  and  slender  hypodermic  needle,  ten  to  fifteen  drops  of 
Majendie's  solution  of  morphia  directly  into  the  sac  ;  and,  3d,  by  drawing 
off  the  liquor  amnii  by  a  very  small  aspirator  needle  with  antiseptic  pre- 
cautions. In  the  last  two  operations  mentioned  the  needle,  first  immersed 
in  boiling  water,  should  be  thoroughly  carbolized  before  being  used,  the  solu- 
tion employed  should  be  carbolized,  and  the  puncture  brushed  thoroughly 
with  carbolized  solution  and  painted  with  collodion. 

The  puncture  of  the  extra-uterine  ovisac  has  been  performed  in  a 
number  of  instances  with  good  results ;  viz.,  twice  by  Morton,  and  once 
each  by  Greenhalgh,  Stoltz,  and  Koeberle.  I  have  resorted  to  this  plan 
twice,  and  lost  both  patients.  One  died  of  septicaemia ;  the  other  of 
hemorrhage  into  the  sac  and  rupture.  Dr.  Routh  has  recently  reported  a 
case  which  ended  fatally  after  the  same  operation,  as  my  second  one  did. 

(b)  The  pregnancy  being  to  all  appearances  one  of  tubal  variety,  and 
immediate  action  being  demanded  by  severity  of  symptoms,  two  courses 
offer  themselves.  1st,  if  the  tumor  be  certainly  accessible  from  the 
pelvis,  it  may  be  cut  freely  into  by  a  dull,  incandescent  point,  like  the 
knife  of  Paquelin's  thermo-cautery,  the  foetus  removed,  hemorrhage  con- 
trolled by  a  firm  tampon,  septicaemia  prevented  by  antiseptic  injections, 
and  the  placenta  allowed  to  come  away  of  itself;  2d,  the  operation  of 
laparotomy  may  be  performed,  the  broad  and  ovarian  ligaments  and  the 
Fallopian  tube  be  included  as  a  pedicle  in  a  ligature,  and  the  foetal  mass 
be  removed. 

From  my  present  experience  I  should  say  that  if  the  tumor  be  low  in 
the  pelvis,  fluctuation  in  it  be  beyond  doubt,  and  reaching  the  sac  certain, 
the  safest  and  best  method  of  dealing  with  the  case  would  be  to  introduce 
a  large  Sims's  speculum,  and,  bringing  the  dull  cautery  of  Paquelin's  appa- 
ratus to  a  red  heat,  cut  slowly  into  the  sac.  Then  the  foetus,  but  not  the  pla- 
centa, should  be  removed,  a  linen  bag  filled  with  cotton  used  as  a  compress 
fixed  externally  upon  the  abdomen  over  the  site  of  the  tumor  with  adhe- 
sive plaster,  and  the  sac  carefully  filled  with  antiseptic  cotton,  which  should 
be  renewed  once  in  every  thirty-six  hours.  Listerism  should  be  carefully 
observed.  By  these  means  hemorrhage  can  be  completely  controlled,  and, 
this  danger  and  septicaemia  being  put  aside,  it  is  difficult  to  conceive  what 


TREATMENT.  775 

more  we  can  ask  in  that  class  of  cases.  In  these  cases  also  the  foetus  may 
be  destroyed  by  injections  of  morphia  or  by  a  strong,  interrupted  current, 
and  subsequent  events  be  waited  for. 

(c)  Should  the  pregnancy  unquestionably  be  abdominal,  as  proved  by 
its  advance  beyond  the  period  ordinarily  possible  for  tubal  distention,  and 
by  the  comparatively  small  size  of  the  uterus,  it  should  not  be  interfered 
with  until  the  completion  of  the  full  term.  At  that  time  an  effort  at 
labor  usually  occurs  and  gives  a  signal  for  action.  Should  this  most  for- 
tunate event  occur,  the  crowning  triumph  of  obstetric  surgery  may  be 
reached  in  the  delivery  of  a  living  child  from  a  living  woman  at  full 
term,  as  was  done  by  Jesop,  of  Leeds,  in  a  case  reported  to  the  London 
Obstetrical  Society  a  few  years  ago. 

At  the  present  day,  when  abdominal  surgery  is  so  thoroughly  systema- 
tized and  fully  understood,  and  when  the  great  contributions  to  it  of  the 
illustrious  Lister  have  so  completely  altered  its  results,  it  is  worse  than 
useless  to  quote  the  statistics  of  laparotomy  for  extra-uterine  pregnancy 
collected  by  Campbell  and  others.  A  new  departure  must  be  made  in  the 
subject,  and  the  future  must  make  its  own  record. 

In  these  cases,  where  the  head  passes  downwards  into  the  pelvis,  it 
sometimes  becomes  possible  to  cut  through  the  vaginal  wall,  seize  the  pre- 
senting part  by  the  obstetric  forceps,  and  deliver  a  living  child  from  a 
woman,  only  slightly  endangered  by  the  operation,  almost  per  vias  naturales. 
In  the  year  1816,  Dr.  John  King,  a  country  practitioner,  residing  upon 
Edisto  Island,  on  the  coast  of  South  Carolina,  met  with  just  such  a  case 
as  I  have  pictured,  and  being  both  a  bold  and  original  man,  he  followed 
the  course  to  which  I  have  alluded,  with  the  result  of  saving  mother  and 
child.  This  case  will  be  found  published  in  the  Med.  Repository,  1817, 
and  a  pamphlet  upon  the  subject  by  Dr.  King  is  now  in  the  possession  of 
Dr.  Pooley  of  Yonkers,  N.  Y. 

(d)  Should  delivery  at  full  term  not  be  accomplished,  a  lithopaedion  or 
petrified  infant  may  result  and  be  retained  for  many  years  ;  suppurative 
action  may  occur  in  the  foetal  envelopes,  and  laparotomy  be  subsequently 
resorted  to  as  a  secondary  operation  ;  or,  the  liquor  amnii  being  absorbed, 
the  bones  of  the  child  may  remain  clasped  by  the  foetal  envelopes  and  pro- 
duce dangerous  inflammation  and  ulceration.  Under  these  circumstances 
it  requires  a  great  deal  of  consideration  as  to  the  proper  course  to  pursue'; 
whether  to  interfere  or  to  leave  matters  to  nature.  Even  if  it  be  recognized 
that  interference  will  surely  become  necessary,  the  question  arises  as  to 
the  time  at  which  it  should  be  practised.  In  the  other  varieties  of  extra- 
uterine pregnancy  the  continued  progress  of  gestation  exposes  the  woman 
to  constant  and  steadily  increasing  danger  of  sudden  death.  In  the  abdo- 
minal form  it  not  only  does  not  do  this,  but  it  is,  as  has  been  stated,  often 
the  wise  course  to  allow  the  process  to  continue  until  the  child  arrives  at 
full  development. 


776  EXTRA-UTERINE    PREGNANCY. 

Let  us  suppose  that  either  before  or  after  full  term  of  gestation  the 
child  has  died,  and  it  is  pretty  certain  that  the  woman  carries  her  dead 
offspring  within  the  peritoneal  cavity.  Is  it  wise  on  this  account  at  once 
to  interfere  by  surgical  means  ?  I  think  not.  One  of  the  greatest  dangers 
attaching  to  interference  consists  in  hemorrhage.  The  longer  time  that 
the  placenta  remains  attached  after  foetal  death  the  more  certain  is  it  to 
become  atrophied  and  consequently  less  vascular.  Another  great  danger 
consists  in  septicaemia.  The  more  thoroughly  the  foetal  envelopes  become 
disgorged  and  atrophic  from  loss  of  function,  the  less  likely  is  this  danger- 
ous complication  to  develop.  Judicious  delay  and  cautious  waiting  for 
symptoms  indicative  of  approaching  trouble  are  then,  in  my  opinion, 
decidedly  advisable. 

But  such  delay,  such  waiting  are  by  no  means  to  be  carried  so  far  that 
symptoms  of  septic  absorption  shall  occur.  Non-interference  carried  as 
far  as  this  is  not  less  to  be  deprecated  than  a  rashness  which  results  in 
intemperate  and  premature  resort  to  operation. 

A  foetus  remaining  in  the  abdominal  cavity  long  after  the  full  term  of 
gestation,  having  lost  its  life,  and  being  surrounded  by  intestines  after 
absorption  of  the  liquor  amnii,  or  by  a  purulent  fluid  which  has  replaced 
it,  is  always  an  element  of  great  danger  which  must  become  more  and 
more  aggravated  as  time  passes.  Its  removal  should  be  regarded  only  as 
a  question  of  time,  not  of  propriety.  It  is  true  that  instances  are  on  record 
where  such  contents  have  remained  in  the  bodies  of  unfortunate  women  for 
thirty  and  forty  years,  but  such  cases  are  rare  exceptions  to  the  rule,  and 
the  impropriety  of  leaving  these  women  for  the  remainder  of  their  lives  in 
such  peril  could  be  tolerated  only  in  the  dark  days  of  abdominal  surgery. 

I  have  operated  six  times  for  extra-uterine  pregnancy,  but  never  have 
I  done  so  without  good  reason  for  believing  that  delay  would  be  far  more 
dangerous  than  immediate  interference.  Out  of  the  six  operations,  four 
have  saved  lives  which  were  in  imminent  peril.  Nevertheless,  I  am 
willing  to  accept  as  the  rule  the  precept  that  operative  procedure  in  extra- 
uterine pregnancy  had  better,  if  possible,  be  delayed  until  nature  points 
to  the  channel  of  extrusion  which  she  selects.  The  most  dangerous  of 
men,  however,  are  those  who  implicitly,  unthinkingly  obey  rules.  The 
bold  and  wise  surgeon  is  he  who  keeps  the  rule  for  general  guidance,  break- 
ing it  unhesitatingly  when  an  exceptional  indication  demands  such  a 
course. 

No  fixed  rule  can  apply  to  all  these  cases.  The  following  may  guide 
the  practitioner  in  general,  he  modifying  them  to  suit  the  varying  indica- 
tions which  may  present  themselves : — 

Before  full  term,  should  the  child  developing  in  the  peritoneal  cavity 
be  alive,  its  growth  may  be  carefully  watched,  and  the  end  of  the  ninth 
month  be  waited  for  in  the  hope  of  delivering  at  that  time,  either  by  laparo- 
tomy or  elytrotomy,  a  living  child  from  a  living  woman. 


TREATMENT.  777 

Should  the  child  have  died  early  in  the  pregnancy,  delay  in  interference 
is  advisable,  but  this  should  not  be  carried  to  the  development  of  septicaemia 
or  hectic. 

Should  the  full  term  be  passed  and  the  child  be  still  imprisoned  in 
its  unnatural  resting  place,  the  rule  should  be  to  wait  for  evidences  of 
constitutional  disorder  on  the  one  hand,  and  to  meet  its  development 
promptly  and  decisively  by  succor  on  the  other. 

The  most  favorable  condition  for  laparotomy  is  when  the  foetal  sac  is 
adherent  to  the  abdominal  walls,  and  opening  into  the  peritoneal  cavity 
becomes  unnecessary.  When  the  sac  is  not  thus  adherent,  its  walls 
should  be  stitched  to  those  of  the  abdomen,  the  peritoneum  be  shut  off, 
and  antiseptic  injections  practised. 

If  the  pregnancy  be  interstitial,  the  uterine  cavity  should  be  dilated,  so 
that  palpation  from  within  it  could  be  practised,  and  the  possibility  of 
incision  considered. 

In  case  of  rupture  of  an  extra-uterine  sac  with  steadily  progressing 
hemorrhage  which  threatens  life,  what  course  should  be  pursued?  In 
18G7  Dr.  Stephen  Rogers,  of  this  city,  wrote  a  monograph  strongly  advo- 
cating laparotomy  in  these  cases  for  the  control  of  hemorrhage  under  these 
circumstances.  I  feel  very  sure  of  the  validity  of  his  position,  and  yet 
experience  proves  to  me  that  the  field  for  such  interference,  from  the  diffi- 
culties of  diagnosis,  the  possibility  of  the  patient  rallying,  and  the  usually 
depreciated  nerve  state  from  shock,  is  a  very  limited  one.  In  my  personal 
experience  of  seventeen  cases,  I  have  seen  but  one  in  which  it  could  have 
been  justified.  In  that  case  a  lady  bled  steadily  for  over  forty-eight  hours, 
and  although  I  urged  the  diagnosis  of  tubal  pregnancy  and  the  propriety 
of  laparotomy  very  strongly,  I  was  overruled  as  to  both  points  by  a  strong 
consultation.  A  post-mortem  examination  showed  a  fcetus  near  the  fim- 
briated extremity  of  one  tube  surrounded  by  its  liquor  amnii.  The  sac 
was  not  ruptured,  but  one  vessel  on  its  circumference  was,  and  from  this 
a  fatal  flow  had  occurred.  Laparatomy  would  almost  surely  have  saved 
the  life  of  this  patient. 

Abdominal  surgery  is  too  progressive,  too  steadily  advancing  to  admit 
of  the  application  to  it  of  the  maxim,  "  there  is  no  better  way  of  judging 
of  the  future  than  by  the  past."  What  was  reprehensible  in  abdominal 
surgery  five  years  ago,  has  become  safe  and  practicable  to-day,  and  it  is 
almost  certain  that  the  near  future  will  see  cases  of  laparotomy  success- 
fully performed  for  the  cataclysmic  symptoms  resulting  from  the  rupture 
of  extra-uterine  foetal  cysts.  So  sure  am  I  of  this  that  I  would  now  as- 
sume laparotomy  to  be  the  only  legitimate  resource  in  these  cases  where 
sufficient  delay  has  been  practised  to  convince  the  practitioner  that  death 
is  surely  approaching. 


778  CHLOROSIS. 


CHAPTER    LIII. 

CHLOROSIS. 

Definition  and  Synonyms — This  disease  is  probably  a  neurosis  of  the 
ganglionic  system  of  nerves.  Disordering  the  control  which  this  system 
exerts  over  the  functions  of  organic  life,  it  produces,  as  symptoms  of  its 
existence,  impoverishment  of  the  blood,  constipation,  dyspepsia,  palpita- 
tion, and  menstrual  derangements  and  irregularities. 

Although  it  is  probable  that  it  may  occur  in  the  male  as  well  as  the 
female,  that  it  is  sometimes  met  with  in  women  who  have  passed  the  age 
of  puberty,  and  as  an  exceptional  occurrence  has  been  known  to  affect 
young  children,  the  ordinary  period  of  its  invasion  is  the  time  of  puberty, 
when  the  dormant  functions  of  the  ovaries  are  being  aroused,  and  the  girl 
is  rapidly  passing  into  the  state  of  womanhood.  This  fact  has  led  many 
observers  to  suppose  that  it  is  dependent  upon  some  derangement  in  ovula- 
tion and  menstruation,  but  it  is  more  probable  that  torpidity  of  the  uterus 
and  ovaries  is,  like  the  peculiar  blood  state  which  is  so  characteristic  of 
the  disorder,  merely  a  symptom  of  functional  disease  in  the  sympathetic 
system  of  nerves. 

Chlorosis  has  been  described  under  a  variety  of  names,  as,  for  example, 
Anaemia  or  Spanaemia,  a  kindred  disorder  with  which  it  has  been  com- 
monly confounded  by  writers;  Chloro-anaemia,  Green  Sickness,  Cachexia 
Virginum,  Morbus  Yirginius,  and  many  others. 

Frequency It  is  an  affection  of  great  frequency  in  all  civilized  and 

refined  communities.  The  greater  the  tendency  developed  by  society  to 
luxurious  and  enervating  habits,  the  more  frequently  is  it  encountered. 
Thus  in  large  cities  and  the  higher  walks  of  life  it  is  of  much  more  com- 
mon occurrence  than  in  country  places,  and  among  the  lower  classes, 
where  a  more  natural  and  healthy  existence  is  passed. 

History The  characteristic  feature  of  the  disorder  being  readily  recog- 
nizable, and  of  such  a  nature  as  to  excite  not  only  attention  but  anxiety, 
it  has,  from  the  remotest  times,  received  some  attention  at  the  hands  of 
physicians.  Although,  however,  allusions  to  it  will  be  found  even  in  the 
writings  of  Hippocrates,  Valleix  declares  that  F.  Hoffman,1  who  wrote  in 
the  middle  of  the  eighteenth  century,  was  the  first  who  ever  gave  a  full 
and  satisfactory  description  of  it.     Sydenham,2  who  flourished  in  the  mid- 

•  De  Morb.  Virgin.  2  Syd.  Soc.  Ed.  of  Works,  vol.  ii.  p.  288. 


PATHOLOGY    AND    SYMPTOMS.  779 

die  of  the  seventeenth  century,  describes  "The  Green  Sickness,"  but  dis- 
poses of  the  whole  subject,  symptomatology  and  treatment,  in  exactly  ten 
lines.  During  the  last  century  the  subject  has  attracted  great  attention, 
and,  thanks  to  the  investigations  of  Andral,  Beequerel,  Rodier,  and  others, 
our  knowledge  of  the  pathology  of  the  condition  has  been  greatly  ad- 
vanced. 

Pathology  and  Symptoms Before  approaching  this  part  of  our  sub- 
ject, special  allusion  must  be  made  to  a  fact  which  has  been  already  men- 
tioned, that  chlorosis  and  anaemia  are  frequently  treated  of  as  identical 
affections  under  the  latter  appellation.  The  pathological  condition  found 
to  exist  upon  chemical  analysis  of  the  blood  in  the  two  diseases  is  often 
the  same,  a  diminished  amount  of  red  corpuscles  and  in  time  diminution 
of  all  the  solid  elements  of  the  blood.  Many  of  their  symptoms  are  also 
the  same,  as,  for  example,  pallor,  palpitation  of  the  heart,  dyspnoea,  the 
existence  of  a  loud,  systolic,  cardiac  murmur,  etc.  In  spite  of  these  facts  it 
will  be  noticed  that  even  those  writers  who  treat  of  the  two  conditions 
under  the  name  of  anaemia  are  forced  to  note  the  circumstance  that  there 
is  a  peculiar  form  of  the  disease  which  occurs  about  the  period  of  puberty, 
to  females  only,  and  which  has  characteristics  not  displayed  under  other 
circumstances.  Prof.  Flint,'  in  treating  of  the  etiology  of  anaemia, 
says  :— 

"  The  obvious  causes  may  be  arranged  into  the  three  classes  just  stated, 
viz.  :  First,  causes  which  involve  an  actual  loss  of  red  globules,  as  in  hem- 
orrhages ;  Second,  causes  involving  a  defective  supply  of  material  for  as- 
similation ;  Third,  causes  which  occasion  expenditure  of  those  constituents 
of  the  liquor  sanguinis  on  which  the  production  of  red  globules  is  de- 
pendent. 

"  The  causes  are  not  always  apparent.  Anaemia  is  apt  to  occur  in  females 
at  or  near  the  age  of  puberty,  when  there  has  been  no  loss  of  blood,  no  de- 
ficiency in  alimentary  supplies,  and  no  unusual  expenditure  of  blood  plasma. 
Under  these  circumstances  it  constitutes  the  affection  to  which  the  name 
Chlorosis  was  applied  before  the  anaemic  condition  was  fully  understood. 
If  the  name  be  retained,  it  should  be  considered  as  denoting  anaemia  occur- 
ring under  the  circumstances  just  stated." 

I  have  introduced  this  quotation  not  merely  for  the  purpose  of  citing 
the  views  of  the  eminent  author  from  whom  it  is  drawn,  but  as  illustrative 
of  the  position  of  those  who  look  upon  these  disorders  as  identical  as  to 
pathology,  and  differing  only  in  the  period  of  life  at  which  they  are  devel- 
oped. As  I  proceed  with  the  description  of  the  symptoms,  course,  and 
treatment  of  chlorosis,  I  hope  to  be  able  to  justify  myself  in  following  the 
example  of  Beequerel,  Valleix,  and  many  other  French  writers,  in  look- 
ing upon  them  as  essentially  and  entirely  different  in  nature. 

Several  French  pathologists,  under  the  lead  of  Beequerel,  of  Paris,  have 

1  Flint's  Practice  of  Med.,  2d  ed.,  p.  62. 


780 


CHLOROSIS. 


of  late  years  advanced  the  view  that  chlorosis  differs  from  anaemia  mainly 
in  this :  that  the  latter  is  merely  a  blood*  state,  while  the  former  is  a  dis- 
ease of  the  nervous  system  which  may  or  may  not  produce  the  latter. 

The  most  striking  differences  between  the  two  diseases  may  be  thus 
contrasted: — 


ANEMIA 

Is  merely  impoverishment  of  the  blood 
due  to  want  of  nourishment,  from  some 
drain  upon  the  system,  or  from  some 
poison  in  the  blood. 

Can  usually  be  accounted  for  by  dis- 
covery of  some  special  cause. 

Occurs  at  all  periods  of  life,  to  men, 
women,  and  children. 

Is  readily  curable  by  removal  of  cause, 
supply  of  good  diet,  and  administration 
of  iron. 

Is  always  characterized  by  impover- 
ishment of  blood. 

Produces  a  puffy  and  pale  appearance. 

Does  not  ordinarily  produce  sadness 
or  great  nervous  disquietude. 

Is  not  especially  accompanied  by  vis- 
ceral neuralgia. 

No  special  affection  of  solar  plexus  of 
nerves. 

Iron  always  does  good. 

The  cause  of  the  disease  being  re- 
moved, patient  will  rapidly  improve. 


CHLOROSIS 

Is  a  disease  of  the  nervous  system,  and 
may  occur  with  or  without  the  production 
of  its  most  common  sympton,  anaemia. 

Cannot  usually  be  accounted  for  by 
discovery  of  special  cause. 

Occurs  in  true  type  usually  to  girls 
about  time  of  puberty. 

Is  affected  favorably  only  by  remedies 
which  act  upon  the  nervous  system,  as 
alteratives  and  tonics. 

Sometimes  exists  without  impoverish- 
ment of  the  blood. 

Produces  a  light  green  color. 

Commonly  produces  sadness  and  ner- 
vous disquietude. 

Is  constantly  accompanied  by  visceral 
neuralgia. 

Pain,  uneasiness,  or  distress  commonly 
referred  to  solar  plexus. 

Iron  often  fails  to  benefit. 

If  supposed  cause  be  removed,  patient 
will  often  improve  but  slowly. 


The  rapid  development  by  which  the  girl  becomes  a  woman  and  the 
boy  changes  to  the  man  is  at  once  one  of  the  most  striking,  important,  and 
interesting  of  the  physiological  processes  which  take  place  in  the  animal 
economy.  The  special  alterations  occurring  at  this  time  do  not  need 
enumeration  here.  All  that  it  will  be  necessary  to  say  is  that  all  this 
change  is  coincident  with  the  development  of  the  ovaries  in  the  one  case 
and  the  testicles  in  the  other,  so  that  the  former  organs  become  capable  of 
casting  off  matured  ovules,  and  the  latter  of  secreting  fructifying  zoo- 
sperms.  If  any  accident  occur  so  that  growth  and  development  do  not 
take  place  in  ovaries  or  testicles,  the  result  is  that  the  girl  never  becomes 
a  fully  developed  woman,  or  the  boy  grows  up  a  shrill-voiced,  beardless, 
effeminate  man. 

In  the  lower  order  of  animals,  and  more  especially  in  the  males  of  many 
species,  interference  by  castration  with  development  at  puberty,  gives  us 
still  more  remarkable  results.  If  two  colts  be  bred  in  the  same  stable  and 
from  the  same  stock,  and  one  be  castrated  and  the  other  left  entire,  the 
former  will  develop  into  the  gentle,  slender  gelding;  while  the  latter  will 


TATIIOLOGY    AND    SYMPTOMS.  781 

grow  into  the  strong-necked,  majestic,  and  vicious  stallion.  A  still  more 
striking  contrast  will  be  found  to  exist  between  the  ox  and  the  bull. 

This  process  of  development,  which  we  term  puberty,  is  under  the  con- 
trol of  the  ganglionic,  or  sympathetic  system  of  nerves,  which,  at  that 
time,  must  necessarily  be  in  a  condition  of  excessive  susceptibility.  It  is 
probable  that  in  that  state  of  exaltation,  it  is,  in  the  female,  often  affected 
by  a  functional  derangement  which  creates  the  collection  of  symptoms  to 
which  we  give  the  name  of  Chlorosis.  I  say  it  is  probable,  for  it  must  be 
confessed  that  the  theory  which  I  have  here  stated  is  merely  an  hypothesis 
suggested  by  clinical  observation  of  such  cases,  and  not  supported  by  post- 
mortem or  other  physical  evidence. 

To  state  this  view  in  other  words ;  at  the  critical  age  of  puberty,  when 
a  series  of  important  and  peculiar  changes  are  being  effected  through  the 
instrumentality  of  the  sympathetic  system  of  nerves,  the  system  seems,  in 
the  female,  to  be  liable  to  a  morbid  influence,  which,  in  great  degree, 
paralyzes  it,  and  impairs  its  functions.  Sadness,  nervousness,  and  irasci- 
bility mark  its  onset ;  then  neuralgia  develops  in  the  limbs,  the  head,  and 
the  viscera ;  the  appetite  is  impaired ;  digestion  becomes  weak,  and  dys- 
pepsia, flatulence,  and  depraved  tastes  are  encountered.  The  girl  craves 
the  most  unpalatable  and  innutritious  substances,  as,  for  example,  chalk, 
clay,  slate,  and  other  articles  of  alkaline  character ;  while,  at  other  times, 
the  taste  prompts  her  to  consume  acids,  as  vinegar,  lemon-juice,  pickled 
vegetables,  etc.  Usually  the  process  of  blood-making  is  soon  disordered, 
and  anaemia  sets  in,  coincidently  with  amenorrhoea,  constipation,  palpita- 
tion of  the  heart,  sensitiveness  along  the  spine,  distress  in  the  solar  plexus 
of  nerves,  coldness  of  the  hands  and  feet,  and  irregular  and  excessive 
flushing  of  the  face. 

Raciborski,1  from  his  allusions  to  the  affection  in  his  work  upon  "  Puberty 
and  the  Change  of  Life,"  evidently  regards  its  pathology  as  due  to  dis- 
order affecting  the  ganglionic  nervous  system : — 

"  Chlorosis  is  an  affection  very  common  with  young  women  about  the 
period  of  puberty.  This  is  not  the  place  for  me  to  discuss  the  primary 
nature  or  the  remote  cause  of  this  disease,  to  inquire  if  it  commences  in 
the  alteration  of  the  blood  which  characterizes  it,  or  if,  on  the  other  hand, 
as  appears  more  probable,  the  alteration  just  alluded  to  is  itself  a  con- 
sequence of  an  affection  of  an  important  part,  such,  for  example,  as  the 
great  sympathetic  nerve,  which,  by  its  numerous  relations,  would  explain 
at  the  same  time  both  this  alteration  of  the  blood  and  various  troubles  in 
the  digestive,  respiratory,  and  genital  organs,  and  all  the  disorders  of  gene- 
ral sensibility." 

Upon  pressing  along  the  spine,  a  point  of  great  sensitiveness  will  usu- 
ally be  found  near  the  seventh  cervical  vertebra,  and  others  are  often  dis- 

1  De  la  puberte",  and  de  Page  critique  chez  la  feinme,  p.  240. 


782  CHLOROSIS. 

covered  above  and  below  this.  Auscultation  reveals  a  loud,  basic,  systolic, 
cardiac  murmur,  and  along  the  arteries  the  bruit  de  souffle  can  be  detected. 
It  is  not  rare  to  find  the  sternum  and  clavicles  very  sensitive  to  pressure ; 
as,  likewise,  the  intercostal  spaces. 

Most  of  these  are  symptoms  which  mark  the  effect  of  the  disease  upon 
the  nervous  system.  The  peculiar  blood  state  usually  engendered  has, 
however,  received  special  attention,  and  been  by  many  excellent  authori- 
ties regarded  as  the  main  element  of  the  disease.  Becquerel,1  in  his  ex- 
cellent article  upon  this  subject,  thus  sums  up  the  changes  which  are 
ordinarily  effected  in  this  fluid  : — 

"  1st.  The  water  of  the  blood  is  notably  augmented,  which  diminishes 
the  density  of  this  fluid.  The  amount  is  represented  by  the  same  figures 
as  in  anaemia. 

"  2d.  The  proportion  of  the  globules  is  diminished. 

"  3d.  The  fibrin  is  usually  found  to  be  normal  in  amount. 

"  4th.  The  fatty  and  saline  constituents  retain  their  normal  proportions, 
as  does  usually  the  albumen.  In  very  severe  and  obstinate  cases,  how- 
ever, the  albumen  is  diminished,  when  we  see  dropsical  swellings  as  a 
result." 

German  pathologists  very  generally  appear  to  repudiate  the  nervous 
theory  of  the  production  of  chlorosis,  and  Rokitansky  and  Virchow  have 
advanced  the  statement  that  severe  and  incurable  cases  are  due  to  an 
aplasia,  or,  as  Virchow  would  express  it,  a  hypoplasia  of  the  heart  and 
large  arteries,  and  a  defective  development  of  the  genital  system.  Accord- 
ing to  them  the  disease  is  of  congenital  rather  than  acquired  character. 

Mode  of  Development Chlorosis  generally  develops  itself  very  insid- 
iously. In  a  girl  who  has  previously  been  in  good  health,  languor,  sad- 
ness, and  aversion  to  company  usually  first  attract  attention.  These  are 
followed  by  palpitation  of  the  heart  after  exertion,  scantiness  of  the  men- 
strual flow,  and  a  characteristic  pale  or  greenish  complexion.  Alarm  is 
ordinarily  excited  by  these  evidences  of  approaching  disease,  and  careful 
scrutiny  soon  discovers  others  which  have  been  already  alluded  to.  Ac- 
cording to  my  observation,  the  first  suspicion  which  usually  takes  posses- 
sion of  the  minds  of  the  friends  of  the  patient  is,  that  pulmonary  consump- 
tion, or  heart  disease,  is  about  to  develop  itself.  In  some  cases,  an 
effusion  of  serum  takes  place  into  the  areolar  tissue  of  the  body,  into  the 
pleural  cavities,  or  into  the  peritoneum,  when  even  the  medical  adviser  is 
deceived,  and  fears  that  dropsy  from  Bright's  disease,  cardiac  disease,  or 
chronic  peritonitis  is  about  to  show  itself. 

If  an  error  in  diagnosis  lead  to  neglect  of  appropriate  treatment,  or  if, 
as  is  worse,  the  symptoms  of  the  disease  be  mistaken  for  those  of  plethora, 
as  I  have  more  than  once  known  them  to  be,  the  gravest  features  of  the 

1  Mai.  de  l'Ute'rus,  t.  ii.  p.  490. 


CAUSES  —  VARIETIES.  783 

affection  will  show  themselves,  and  a  most  critical  condition  be  estab- 
lished. 

Causes. — The  predisposing  causes  are  well  known  to  be  sex  and  age ; 
but  those  which  absolutely  excite  the  disorder  are  not  so  easily  ascertained. 
The  causes  which  are  here  recorded  are  probably  those  which  most  fre- 
quently prove  active ;  but  it  must  be  specially  stated  that,  in  the  majority 
of  cases,  no  cause  whatever  can  be  assigned  for  the  disease. 
Great  grief,  or  prolonged  mental  anxiety ; 
Depressing  home  influences  ; 
Great  fear  suddenly  excited  ; 
Deprivation  of  pure  air,  exercise,  and  light ; 
Disappointment  in  love  ; 
Erotic  excitement  without  gratification  ; 
Prolonged  watching  and  loss  of  sleep ; 
Nostalgia ; 

Excessive  mental  labor. 
The  most  marked  instances  of  the  disease  which  have  fallen  under  my 
observation  have  occurred  under  the  influence  of  great  grief  for  the  loss 
of  a  relative,  disappointment  in  love,  or  home-sickness.  Dr.  W.  H.  Ham- 
mond, in  an  interesting  article  upon  this  subject,  published  in  the  Psycho- 
logical Journal  for  July,  1868,  records  a  striking  instance  arising  from 
sudden  and  extreme  fear. 

Before  leaving  this  part  of  the  subject,  it  is  proper  that  I  should  state 
that  Becquerel,  who  has  done  more  for  the  advancement  of  our  knowledge 
of  this  interesting  affection  than  any  other  modern  authority,  admits  these 
causes  with  considerable  reserve.  They  "can,  if  they  do  not  produce,  at 
least  favor  the  development  of  chlorosis,"  says  he  in  reference  to  most  of 
those  causes  which  I  have  recorded. 

Varieties I  know  of  no  good  reason  for  dividing  chlorosis  into  varie- 
ties. In  one  set  of  cases,  certain  symptoms  are  predominant;  in  others, 
a  different  set  of  signs  assume  the  ascendency.  It  may,  however,  prove 
useful  to  the  reader  to  lay  before  him  the  six  forms  which  have  been 
adopted  by  Becquerel.  They  are  as  follows : — 
1st  form,  simple  chlorosis  ; 

2d      "     chlorosis  with  predominance  of  cephalalgia  ; 
3d      "  "  "  "  dyspnoea  and  palpitation ; 

4th     "  "  "  "  gastralgia; 

5th     "  "  "  "  menstrual  disorder ; 

6th    "  "  "  "  general  feebleness. 

Differentiation An  aggravated  case  of  this  disease  may  be  confounded 

with  anaemia,  cardiac  disease,  tubercular  pleuritis  or  peritonitis,  or  even 
with  the  first  stage  of  tubercular  phthisis.  From  all  these  a  careful  and 
intelligent  search  for  the  evidences  of  organic  lesions  will  usually  distin- 


784  CHLOROSIS. 

guish  it  in  time ;  but  without  watching  the  progress  of  the  case  for  a  con- 
siderable period,  it  is  often  impossible  to  decide  as  to  the  diagnosis. 

The  physician  is  frequently  deterred  from  arriving  at  a  positive  conclu- 
sion as  to  the  existence  of  chlorosis,  by  imagining  that  the  disorder  is 
identical  with  anaemia.  Drawing  from  the  veins  of  the  patient  a  drop  of 
blood,  he  puts  it  under  the  microscope,  and  to  his  surprise  finds  it  to  con- 
tain red  globules  in  normal  amount,  and  concludes  that  his  suspicions 
were  incorrect.  It  is  a  well-known  fact  that  the  disease  may  exist  in 
aggravated  form  with  little  or  no  blood  change. 

Complications Chlorosis  may  be  complicated  by  hysteria,  hypochon- 
driasis, hypertrophy  of  the  heart,  and  tuberculosis.  In  one  case  which  I 
have  seen,  chlorosis  developed  itself  with  most  unmistakable  symptoms, 
and  then  violent  chorea  showed  itself,  which  proved  fatal  after  lasting 
about  two  years. 

Prognosis Unless  some  serious  disorder  complicate  it,  the  prognosis 

is  always  good  ;  but  the  course  and  duration  of  the  disease  cannot  be 
predicted.  If  all  the  surroundings  of  the  patient,  both  social  and  physical, 
be  altered,  and  all  causative  influences  removed,  recovery  may  be  rapid 
and  complete ;  but  if  these  changes  cannot  be  brought  about,  the  affec- 
tion may  last  for  an  indefinite  time. 

Treatment. — Treatment  should  consist,  not  in  fruitless  attempts  to  over- 
come one  or  even  two  of  the  results  of  the  disease,  amenorrhcea  and  anaemia, 
for  example,  but  in  a  systematic  effort  to  accomplish  these  three  ends  : — 
1st.  To  remove  the  cause  of  the  disorder; 
2d.  To  cure  the  neurosis  itself; 
3d.  To  repair  the  damage  which  it  has  effected  in  the  system. 

If  any  one  of  the  causes  which  have  been  enumerated  be  found  to  exist, 
it  should,  as  far  as  possible,  be  promptly  and  entirely  removed.  In  many 
cases  the  cause  cannot  be  discovered,  and  in  many,  if  discovered,  cannot 
be  removed ;  but  if  search  be  always  made  for  it,  a  sufficient  number  of 
successes  will  occur  to  reward  the  effort. 

Even  where  the  special  cause  cannot  be  detected,  recovery  may  be 
attained  by  removing  the  patient  from  home,  and  sending  her  to  a  dis- 
tance from  objects  and  people  connected  with  the  sadness  and  depression 
attendant  upon  the  inception  of  the  attack.  A  visit  to  some  agreeable 
watering  place  or  lively  country  resort,  if  the  patient  live  in  a  city,  or  to 
some  large  and  busy  city,  if  she  reside  in  the  country,  will  often  do  more 
in  the  way  of  cure  than  can  be  effected  by  any  amount  or  kind  of  medica- 
tion. A  sea-voyage  and  visit  to  a  foreign  country  will  often  produce  a 
most  excellent  result,  and  sometimes  cause  complete  cure. 

"Well -regulated  exercise  in  the  open  air  is  of  great  importance.  Horse- 
back exercise,  rowing,  bowling,  walking,  playing  at  croquet,  tennis,  etc., 
constitute  some  of  our  best  nervous  tonics.  Sea-bathing,  and  more  parti- 
cularly surf-bathing,  is  very  useful,  and  should,  when  attainable,  be  faithfully 


TREATMENT.  785 

tried.  All  of  these  are,  however,  inferior  in  value  to  cheerful  and  con- 
genial society.  This  accomplishes  a  change  in  the  nervous  system  which 
nothing  else  so  surely  effects. 

In  the  mean  time,  nervous  tonics  should  be  freely  given.  The  best  of 
these  are  the  preparations  of  the  hypophosphites,  arsenic,  strychnine,  and 
quinine.  Should  the  patient  bear  it  well,  the  continuous  electric  current 
should  be  employed,  and  general  electrization  often  proves  very  beneficial. 

As  anaemia  is  usually  a  complication  of  the  disease,  iron  is  generally 
indicated.  Some  of  the  best  preparations  are,  the  saccharated  carbonate, 
iron  by  hydrogen,  dialyzed  iron,  and  the  bitter  wine  of  iron.  A  very 
excellent  combination  is  offered  in  the  following  prescription  : — 

I£. — Ferri  vini  amari,  §vijss. 
Tr.  nucis  vomicae,  $iv. 
Solut.  potassfe  arsen.  5'j- — M. 
S. — A  dessertspoonful  in  a  claret-glassful  of  water  just  after  each  meal. 

The  diet  should  be  extremely  nutritious,  consisting  of  meat,  milk, 
animal  broths,  eggs,  and  vegetables,  with  wine,  whiskey,  or  malt  liquors, 
if  they  appear  to  be  well  borne  by  the  patient. 

Should  the  pathology  of  severe  cases  be,  as  suggested  by  some  of  the 
most  eminent  German  pathologists,  an  undeveloped  state  of  some  of  the 
important  organs  of  the  body,  of  course  nothing  will  result  from  treatment 
except  palliation  by  improvement  of  the  existing  blood  and  nerve  states. 


50 


INDEX. 


ABDOMEN,    applications    to,    in   peri- 
tonitis, 751 

anatomy,  regional,  of,  367 
Abdominal  ovariotomy,  733 

pad  in  anterior  displacements  of  the 

litems,  418 
palpation  conjoined  with  use  of  the 
sound,  90 
in  physical  examination,  89 
supporter  after  ovariotomy,  755 
viscera,  distention  of,  differentiated 
from  ovarian  tumor,  706 
Ablation  of  uterus,  545 
cases,  546 

methods  of  removal,  548 
operation,  Plan's,  548 
Schroeder's,  549 
Thomas's,  549 
statistics,  547 
Abnormal  growths  a  cause  of  sterility, 

650 
Abortion,  induction  of,  a  cause  of  disease 

among  women,  50 
Abscess  and  cyst  of  vulvo-vaginal  gland, 

126 
Abscess,  pelvic  (see  Pelvic  abscess),  502 
Absence  and  rudimentary  state  of  the 
ovaries,  119 
of  the  uterus  and  ovaries,  115 
of  the  vagina,  119 

treatment,  229 
Acne  of  the  vulva,  128 
Adenoma  of   the  uterus,  566  (see    Sar- 
coma of  the  uterus). 
Air-pessary  described  by  the  ancients,  21 
Amenorrhcea,  635 
causes,  636 
definition,  635 
differentiation,  638 
frequency,  636 
menopause  a  cause  of,  638 
pathology,  636 

tardy  menstruation  a  cause  of,  638 
treatment,  general,  638 
local,  640 

baths,  641 
cupping  in,  641 
electricity,  640 
enemata,  stimulating,  641 
sound,  passage  of,  640 
tents,  640 


Amenorrhoea — 

varieties,  636 
Amputation  of  the  neck  of  the  uterus, 
652 
conditions  demanding,  653 
dangers,  653 
history,  652 

operation  by  bistoury,  654 
by  ecraseur,  654 
by  galvano-cautery,  655 
methods  of  performing,  654 
scissors,  654 
varieties  of,  654 
of  the  uterus  for  inversion,  methods 
of,  471 
objections  to,  472 
Amussat's  operation  for  atresia  vaginse, 

230 
Anaamia,    distinguished    from   chlorosis, 

780 
Anaesthesia  in  physical  diagnosis,  87 
Anatomy  of  the  ovaries,  658 
Ancient  specula,  23 
Angioma,  venous,  urethral,  150 
Anomalies  of  uterine  development  dur- 
ing childhood,  119 
Anteflexion  of  the  uterus,  410 

axes  of  the  uterus  in  different 

flexions,  411 
definition,  410 
incurable  flexions,  417 
irreducible  flexions,  414 

operation  for,  429 
physical  signs,  412 
prognosis,  412 
reduction,  means  of,  413 
statistics,  406 
symptoms,  411 
varieties,  410 
Anterior   displacements  of  the    uterus, 
405 
abdominal  pad  in,  41S 
supporter  in,  418 
anteflexion,  410 
Elliot's  uterine  repositor,  415 
Jennison's  sound,  415 
maxims  for  treating,  425 
means  for  reduction,  413 

of  retention,  417,  418 
operation   for  irreducible    flex- 
ions, 429 

(787) 


788 


INDEX. 


Anterior  displacements  of  the  uterus — 
pessaries  in,  420 

intra-uterine,  413 

maxims  for  using,  425 
section  of  the  cervix  in,  431 
Sims's  knife  used  in,  431 
Wallace's  spring  tent  in,  416 
Anteversion  of  the  uterus,  405 
causes,  exciting,  407 

predisposing,  407 
course,  408 
definition,  405 
degrees  of,  409 
diagnosis,  409 
differentiation,  409 
dorsal  decubitus  in,  417 
duration,  408 
frequency,  405 

influences  dragging  fundus  for- 
wards, 407 

enfeebling     uterine     sup- 
ports, 407 

forcing    fundus    forwards, 
407 

increasing  weight   of  ute- 
rus, 407 
pessaries,  420 

Cutter's,  420 

Fowler's,  425 

Hewitt's,  424 

Thomas's,  421,  422 

stem,  426,  428,  429 
pressure,  removal  of,  417 
prognosis,  410 
reduction,  means  of,  413 
statistics,  406 
symptoms,  408 
termination,  408 
treatment,  413 
varieties,  408 
Apoplexy,  ovarian,  663 
definition,  663 
prognosis,  664 
symptoms,  664 
treatment,  664 
Apparatus,  Bozeman's  securing,  431 
Areolar  hyperplasia  of  the  uterus,  307 
amputation,  partial,  of  the  cer- 
vix for,  336 
Beck,  Snow,  on,  315 
Bennett,  J.  II.,  on,  310 
blisters  in,  335 
causes  exciting,  324 

predisposing,  323 
cervical,  physical  signs  of,  325 
complications,  327,  328 
consequent    on    subinvolution, 

314,  316 
corporeal,    physical    signs    of, 

325 
course,  321 

cupping  the  cervix  for,  333 
definition,  : i* » T 
differentiation,  326 


Areolar  hyperplasia  of  the  uterus — 

due   to   non-puerperal   causes, 

319 
frequency,  321 
Gallard  on,  317 
Klob  on,  320 
nomenclature,  308 
mineral  waters  in,  332 
pathology,  313 

resume1  of  article  on,  320 
physical  signs  of  cervical,  325 

of  corporeal,  325 
prognosis,  327 
resume  of  article  on  pathology 

of,  320 
stages  in,  320 
symptoms,  324 
termination,  321 
treatment,  328 
general,  332 
indications  for,  330 
local,  alterative,  334 
depletion,  332 
injections,     emollient, 

vaginal,  334 
vesication,  335 
rest  as  a  means  of,  330 
varieties,  321 
West  on,  315 
Ascent  of  the  uterus,  381 
Ascites     differentiated      from     ovarian 

dropsy,  707. 
Aspiration  in  diagnosis  of  ovarian  tu- 
mor, 715 
Aspirator  as  a  means  of  diagnosis,  109 

Dieulafoy's,  109 
Astringents  in   treatment  of  prolapsus 

uteri,  398 
Atresia  of  the  genital  tract  and  retention 
of  blood  and  other  fluids,  220 
definition,  220 
synonyms,  220 
Atresia  of  the  uterus,  221 
causes,  221 
definition,  221 
diagnosis,  222 
differentiation,  222 
frequency,  221 
prognosis,  221 
results,  222 
Atresia  of  the  vagina,  224 
causes,  225 

Dupuytren's  operation  for,  229 
history,  224 
pathology,  225 
physical  signs,  226 
prognosis,  226 
results,  226 
symptoms,  225 
treatment,  227 

Amussat's  operation,  230 
Lefort's  operation,  232 
when    due   to   closure    by 
diaphragm  or  hymen, 228 


INDEX. 


789 


Atresia  df  the  vagina,  treatment — 

where    there    is  atresia  of 

the  uterine  neck,  227 
where   there  is  (Insure  or 
absence  of  vagina,  229 
varieties,  224 
Atresia,  uterine,  at  os  externum,  223 
at  os  internum,  223 
in  one  half  of  a  double  uterus, 
223 
Atrophy  of  the  ovary,  6(32 
causes,  I)lj2 
treatment,  663 
Auscultation  and  percussion  as  a  means 

of  diagnosis  for  pelvic  disease,  111 
Aveling's  polyptome,  535 
Axes  of  the  uterus,  411 
Axis  of  the  uterus  in  flexions,  430 


BANDAGING,  tight,  after  parturition, 
a  frequent  source  of  disease  among 
women,  48 
Baths  in  amenorrhea,  641 
Battery,  Byrne's  galvano-caustic,  655 
Battey's  operation,  756 

estimate  of,  759 
Bicorn  uterus,  118 
Bilateral  laceration  of  the  cervix  uteri, 

356 
Bivalve  speculum,  23 
Bladder,  prolapse  of,  172 
Bozeman's  securing  apparatus,  731 
Broad  ligament,  cysts  of,  696 
Bulbs  of  the  vestibule,  anatomy,  130 
rupture  of,  130 


CANCER  of  the  uterus,  571 
body,  cancer  of  the,  differentia- 
tion, 590 
peculiar   features    of, 
590 
causes,  exciting,  5S5 

predisposing,  584 
cervix,  amputation  of,  594 
complications,  589 
definition,  571 
differentiation,  587 
early  views  on,  26 
encephaloid,  576 
epithelial,  577 

opinions    about   pathology 

of,  580 
vegetating,  581 
epithelioma,  vegetating,  583 
extirpation  of  the  uterus    for, 

598 
frequency,  574 

relative,   of  the    varieties, 
574 
history,  571 

part  of  the  uterus  affected  in, 
589 


Cancer  of  the  uterus — 
pathology,  572 
physical  signs,  586 
prognosis,  588 
scirrhous,  576 
Simon's  scoop,  595 
symptoms,  585 
treatment,  591 

constitutional,  598 
resume  of,  600 
varieties,  573 
Cancer,  epithelial,  of  the  cheek,  578 

vegetating,  581 
Cancerous  ulcerations  of  the  uterus,  29 
Carcinoma  of  the  ovary,  673 
Caruncle,  urethral,  irritable,  147 
causes,  147 
course,  148 
differentiation,  148 
duration,  148 
pathology,  147 
physical  signs,  148 
prognosis,  148 
treatment,  148 
Catheter,  Sims's  sigmoid,  251 
Causes  of  disease,  exciting,  tabulation 
of,  54 
predisposing  to  diseases  of  women, 
42 
Cellular  polypus,  559 
Cellulitis,  periuterine,    475    (see    Peri- 
uterine cellulitis). 
Cervical  constriction,  treatment  of,  615 
dilators,  Molesworth's,  534 
hyperplasia  of  the  uterus,  321 
leucorrhoea,    microscopical    appear- 
ance of,  645 
mucous  membrane,  anatomy  of,  276 
speculum,  Wylie's,  299 
Cervix,  conoidal,  650 

dilator,  Priestley's,  for,  616 
Cervix    uteri,   amputation   of,   652   (see 
Amputation   of    the  neck  of 
the  uterus), 
for  cancer,  594 
cystic  degeneration  of,  342  (see  Cys- 
tic  degeneration    of    the    cervix 
uteri), 
follicular  degeneration  of,  342  (see 
Cystic  degeneration  of  the  cervix 
uteri), 
forceps  for  amputating,  593 
granular  and  cystic  degeneration  of, 
336 
Cervix  uteri,  granular,  337 

causes,  exciting,  337 

predisposing,  337 
course,  339 
definition,  337 
duration,  339 
frequency,  337 
pathology,  339 
physical  signs,  339 
prognosis,  339 


790 


INDEX. 


Cervix  uteri,  granular — 
symptoms,  338 
treatment,  339 
Cervix  uteri,  laceration  of,  352 
anatomy,  353 
bilateral,  356 
causes,  354 
definition,  352 
denuded,  360 
differentiation,  358 
frequency,  352 
history,  352 
pathology,  353 
physical  signs,  355 
prognosis,  359 
results,  358 
"stellate,"  357 
sutures  passed  in,  361 

twisted  in,  362 
symptoms,  355 
synonyms,  353 
treatment,  359 
unilateral,  357 
varieties,  353 
Cervix  uteri,  oedematous  elongation  with 
prolapsus  of  the,  390 
posterior  section  of,  in  flexions,  431 
syphilitic  ulcer  of,  344 
course,  345 
differentiation,  345 
frequency,  344 
termination,  345 
treatment,  345 
Chlorosis,  778 

blood  changes  in,  782 
causes,  783 
complications,  784 
definition,  778 
development,  mode  of,  782 
differentiation,  780,  783 
frequency,  778 
history,  77* 
pathology,  779 
prognosis,  784 
symptoms,  779 
synonyms,  778 
treatment,  784 
varieties,  783 
Chronic  cervical  endometritis,  275  (see 
Endometritis,  chronic  cervical), 
parenchymatous  metritis,  307  (see 
Areolar   hyperplasia  of  the  ute- 
rus). 
Clamp,  Dawson's   temporary,  in  ovari- 
otomy, 740 
Thomas's,  for  securing  the  pedicle 
in  ovariotomy,  741 
used    in    removal    of     uterine 
fibroid  tumors,  550 
Clitoris,  anatomy  of,  121 
Closure  of  the  vagina,  224  (see  Atresia 

of  the  vagina). 

Coccyodynia,  151 

auatomy,  151 


Coccyodynia — 
causes,  152 
definition,  151 
differentiation,  151 
frequency,  151 
history,  151 
pathology,  152 
prognosis,  153 
symptoms,  152 
treatment,  153 
Colloid  degeneration  of  the  ovary,  6£0 
Colporrhaphy,  176 

Emmet's  operation,  178 
"posterior,"    180 
Sims's  operation,  177 
Colpo-perineorrhaphy,    Jenks's    opera- 
tion, 203 
Conception,   prevention   of,   a   cause   of 

disease,  50 
Congenital  and  infantile  malformations 
of  the  female  sexual  organs, 
112 
physical  examination  of,  117 
malformations  of  generative  organs, 

varieties,  114 
misplacement  of  the  uterus,  119 
Constipation,  habitual,  a  cause  of  dis- 
ease, 52 
Corporeal   hyperplasia  of    the    uterus, 
321    (see  Areolar  hyperplasia  of  the 
uterus). 
Cup,  Lente's,  for  fusing  nitrate  of  silver, 
287 
and  stem  for  gradual   reduction  of 
inverted  uterus,  465 
Cupping  in  amenorrhea,  640 

cervix  uteri,  hard  rubber  cylinder 
for,  334 
Curette,  dangers  of,  351 
-forceps,  Emmet's,  351 
Recamier's,  27,  350 
Sims's  289 

steel,  350 
Thomas's  wire,  350,  634 
Cylinder  of  hard  rubber  for  dry  cupping 

the  cervix  uteri,  334 
Cyst  of  vulvo-vaginal  gland,  126 
Cystic  degeneration  of  the  cervix  uteri, 
343 
causes,  343 
definition,  342 
pathology,  343 
prognosis,  343 
synonyms,  343 
treatment,  343 
Cystic  degeneration  of  the  chorion,  604, 

605  (see  Uterine  hydatids). 
Cysto-carcinoma  of  the  ovary,  676 
Cystocele,  172 

Cysto-fibroma  of  the  ovary,  677 
Cysto-fibromata,    551    (see    Fibro-cystic 

tumors  of  the  uterus). 
Cystomata  and  cysts,  ovarian,  682  (see 
Ovarian  cysts  and  cystomata). 


INDEX. 


791 


Cysto-sarcoma  of  tho  ovary,  077 
Cysts,  broad  Ligament,  of  the,  090 

dermoid,  of  the  ovary,  079 

hydatid,  K97 

parasitic,  097 

subperitoneal,  099 


DEPRESSOR,  Sims's,  90 
Dermoid  cysts  of  the  ovary,  079 
Descent  of  the  uterus,  381  (see  Prolap- 
sus of  the  uterus). 
Development  of  the  generative  organs, 
113 
uterine,  in  childhood,  anomalies  of 
119 
Diagnosis,  aspirator  as  a  means  of,  109 
exploring  needle  as  a  means  of,  109 
Diagnosis  of  female  diseases,  80 
amesthesia,  87 

examination,     physical,     man- 
agement of  patient  during,  84 
exploration,  vesico-rectal,  92 
manipulation,  conjoined,  88,  89 
inspection,  90 
palpation,  abdominal,  89 

conjoined  with  use  of 
the  sound,  90 
bimanual,  88 
phvsical    diagnosis,    means  of, 

80 
signs,  rational,  82 
speculum,  93 
touch,  rectal,  91 
vaginal,  87 
Diagnosis,   imperfect,    a  frequent   cause 
of  unsuccessful  treatment  of  ute- 
rine disease,  02 
microscope  as  a  means  of,  109 
of  pelvic  disease,  recapitulation  of 

means  used  in,  111 
physical,  means  of,  80 
Diaphragm,  action  of,   in    prolapsus   of ! 

the  uterus,  400 
Dilator,  Molesworth's  uterine,  534 

Priestley's,  for    constricted    cervix, 

010 
Schultze's,  for  the  cervix,  017 
Diseases  of  the  Fallopian  tubes,  700 
anatomy,  700 
displacements,  705 
distention,  704 
inflammation  of,  702 
other  diseases  of  the  tubes,  705 
salpingitis,  702 
stricture,  703 
Diseases  resulting    from   retention    and 
alteration  of  the  foetal  envelopes, 
002 
of  women,  predisposing  causes  of,  42 
Displacement  a   primary  factor  in  ute- 
rine disease,  33 
Displacements  of  the  uterus,  303 
anatomy,  300 


j  Displacements  of  the  uterus — 
anteflexion,  410 
anteversion,  405 
camplications,  375 
congenital,  373 
definition,  300 
etiology  of,  370 
flexions,  causes,  exciting,  378 

predisposing,  378 
frequency,  370 
general  considerations,  303 
history,  303 

influences  exciting  traction  on, 
377,  379 
increasing  weight  of,  377, 

378 
pressing  uterusout  of  place, 

377,  379 
weakening     uterine     sup- 
ports, 377,  378 
pathological  significance  of  ver- 
sions and  flexions,  304 
pathology,  372 
results,  375 
synonyms,  300 
treatment  of  anterior,  413 

of  posterior,  438 
varieties,  309 
Displacements,      uterine,      pathological 

views  upon,  32 
Distention  of  Fallopian  tubes,  704 
Divided  uterus,  118 
Double  uterus,  118 
Drainage  tube,  Thomas's,  740 
Dress,  improprieties  of,  a  predisposing 

cause  of  disease  in  women,  45    . 
Dressing-forceps,  Thomas's,  74 
Dropsy,  tubal,  097,  704 
Dupuytren's  operation  for  atresia  vagi- 
na), 229 
Dysmenorrhea,  GOO 
pathology,  008 
seat  of  pain  in,  008 
varieties  of,  008 
Dysmenorrhoea,  congestive,  611 
causes,  011 
definition,  611 
differentiation,  012 
prognosis,  012 
symptoms,  012 
treatment,  012 
Dysmenorrhoea,  inflammatory,  611  (see 

Dysmenorrhoea,  congestive). 
Dysmenorrhoea,  membranous,  620 
definition,  620 
differentiation,  622 
etiology,  621 
frequency,  622 
membrane  in,  624 
pathology,  020 
prognosis,  023 
symptoms,  022 
treatment,  024 
Dysmenorrhoea,  neuralgic,  009 


792 


INDEX. 


Dysmenorrhea,  neuralgic — 
causes,  609 
differentiation,  609 
prognosis,  610 
symptoms,  609 
treatment,  610 
Dysmenorrhea,  obstructive,  613 
causes,  613 
cervical  constriction,  treatment 

of,  615 
differentiation,  614 
pathology,  613 
prognosis,  615 
symptoms,  614 

treatment  of  cases  caused   by 
fibroids,  620 
by  obturator   hymen, 

620 
by  polypus,  620 
dependent    on    flexion   or 

version,  619 
vaginal  stricture,  620 
Dysmenorrhea,  ovarian,  625 
definition,  625 
pathology,  626 
prognosis,  626 
symptoms,  625 
treatment,  626 
Dysmenorrhea!  membrane,  624 


ECRASEUR,  536 
wire-rope,  Hicks's,  565 
Elastic  sound,  Jenks's,  102 
Electricity  in  amenorrhea,  640 
Elytro-episiorrhaphy,  405 
Elytrorrhaphy,  176 

inferior,  405 
Emmet's  treatment  of  laceration  of  the 

cervix  uteri,  37 
Endometritis,  acute,  268 

causes,  269 

complications,  272 

course,  273 

differentiation,  271 

duration,  273 

frequency,  2(i9 

pathology,  271 

physical  signs,  270 

prognosis,  273 

symptoms,  260 

synonyms,  269 

termination,  273 

treatment,  273 

varieties,  269 
Endometritis,  ehronic  cervical,  275 

anatomy    of    cervical    mucous 
membrane,  276 

causes,  exciting,  278 
predisposing,  277 

course.  277 

curette,  Sims's,  in,  289 

definition,  275 

duration,  2b0 


Endometritis,  chronic  cervical — 
frequency,  275 
pathology,  277 
physical  signs,  277 
prognosis,  281 
symptoms,  279 
synonyms,  276 
termination,  280 
treatment,  281 

applications,       alterative, 
284 
emollient,  283 
diseased    glands,   destruc- 
tion and  ablation  of,  288 
general  regimen,  281 
villi  of  cervical  canal,  276 
Endometritis,  chronic  corporeal,  290 
anatomy,  291 
applications  to  uterine  cavity, 

298 
causes,  exciting,  293 

predisposing,  293 
complications,  298 
course,  297 
duration,  297 
frequency,  290 
ointments,  use  of,  in,  300 
pathology,  292 
physical  signs,  297 
prognosis,  292 

favorable  and  unfavorable, 
contrasted,  293 
symptoms,  295 
synonyms,  290 
termination,  297 
treatment,  298 

application   of    alteratives 
(solid)  to  endometrium, 
300 
injections  into  the  uterine 

cavity,  301 
intra-uterine       injections, 

dangers  of,  302 
Molesworth's    syringe    for 
injecting  uterine  cavity, 
306 
substances  used  for  intra- 
uterine injections,  306 
Endometrium,  application  of  alteratives 

(solid)  to,  300 
Enemata,  stimulating,  in  amenorrhea, 

641 
Enterocele,  173 
Episio-perineorrhaphy,  405 
Kpisiorrhaphy,  405 
Epithelioma,  vegetating,  583 
Erroneous   prognosis   a   frequent   cause 
of  failure  in  treating  uterine  disease, 
62 
Eruptive  diseases  of  the  vulva,  128 
Etiology  of  the  diseases  peculiar  to  wo- 
men, 41 
Examination,  physical,  management  of 
patient  during,  84 


INDEX, 


703 


Excessive  development  of  the  nervous 
system   a  predisposing  cause  of  dis- 
eases of  women,  44 
Exciting  causes   of  diseases  of  women, 

tabulation  of,  !">4 
Exercise     and     physical     development, 
neglect   of,    a   predisposing    cause   of 
diseases  of  women,  43 
Exploring  needle,  as  a  means  of  diag- 
nosis, 109 
External  organs  of  generation,   tumors 

of,  154 
Extirpation  of  the  uterus,  545 
cases,  54(i 

methods  of  removal,  548 
operation,  Pean's,  548 
Schroeder's,  549 
Thomas's,  549 
statistics,  547 
Extra-uterine  pregnancy,  765 
cases,  770 

death,  causes  of,  768 
definition,  766 
differentiation,  769 
etiology,  766 
pathology,  767 
physical  signs,  769 
prognosis,  771 

rupture,  approaching,  symp- 
toms of,  771 
symptoms,  768 
synonyms,  766 
table  of  cases,  772 
treatment,  773 
varieties,  766 


FAILURE   of  successful   treatment   in 
uterine  diseases,  reasons  for,  61 
Fecal  fistuhe,  265  (see  Fistula?,  fecal). 
Female  physicians,  38 
Fever-cot,  Kibbee's,  752,  753 
Fibre  cell  of  fibro-cystic  tumors,  556 
Fibro-cystic  tumors  of  the  uterus,  551 

course,  557 

definition,  551 

differentiation,  554 

duration,  557 

fibre  cell  characteristic  of,  556 

frequency,  551 

pathology,  552 

physical  signs,  554 

prognosis,  557 

symptoms,  554 

synonyms,  551 

termination,  557 

treatment,  557 
Fibroid,  submucous,  560 
Fibroids  causing  obstructive  dysmenor- 
rhea, 62(1 
Fibroid  tumors  of  the  uterus,  519 

Atlee's  views  on  surgical  treat- 
ment of,  533 

avulsion,  537 


Fibroid  tumors  of  the  uterus— 

cases    illustrating    removal    by 

the  "spoon-saw,"  541,  542 
causes,  523 

clamp,  Thomas's,  used   in   re- 
moval of,  550 
complications,  523 
course,  527 

curative  medicinal  means,  529 
surgical  procedures,  532 
Cutter's  treatment  of,  532 
definition,  519 
diagrams  of  cases,  542,  543 
differentiation,  525 

from  partial  inversion,  460 
dilatation  of  the  cervix  uteri, 

534 
duration,  527 
ecrasement,  536 
elastic,    flat   whalebone    probe 

for  examining,  540 
enucleation,  537 
excision,  535 

extirpation,  plans  for  the,  533 
forceps,  Nelaton's,  535 
frequency,  526 

Hildebrandt's  method  of  treat- 
ment, 530 
history,  519 
laparotomy  in,  545 
Molesworth's  dilators,  534 
oophorectomy  in,  551 
operation,  Pean's,  548 
Schroeder's,  549 
Thomas's,  549 
Paquelin's  thermo-cauteryused 
;  in  incising  the  cervix  in,  535 

pathology,  520 
physical  signs,  524 
polyptome,  Aveling's,  535 
prognosis,  526 
removal,  methods  of,  548 
sloughing,  production  of,  538 
"spoon-saw,"  Thomas's,  539 
statistics,  547 
symptoms,  524 
synonyms,  519 
termination,  527 
treatment,  528 
uterine  fibroma,  522 
varieties,  522 
Fibroma  of  the  ovary,  675 
Fibrous  polypus,  560 

tumors  of  the  ovary,  675 
Fistula,  perineo-vaginal,  267 

peritoneo-vaginal,  267 
Fistula?,  blind  vaginal,  267 

entero-vaginal,  267 
Fistula?,  fecal,  265 
causes,  265 
definition,  265 
physical  signs,  266 
prognosis,  266 
symptoms,  265 


794 


INDEX. 


Fistulae,  fecal — 

treatment,  266 
varieties,  265 
Fistulse  of  the  female  genital  organs,  233 
definition,  233 
varieties,  233 
simple  vaginal,  267 
definition,  267 
perineo-vaginal,  267 
peritoneo-vaginal,  267 
uretero-uterine,  263 
uretero-vaginal,  263 
Fistulae,  urinary,  233 

bistoury   for   paring   edges  of, 

246 
causes,  235,  236,  237 
classes,  235 
complications,  238 
edges  of,  bevelled,  247 
elements   of    successful    treat- 
ment of,  240 
elytroplasty,  258 
fork  for  adjusting  sutures  in, 

250 
fulcrum    for    supporting    wire 

while  twisting,  250 
history,  239 

hook  for  engaging  needle  in,  250 
kolpokleisis,  260 
means  for   obtaining  a  natural 

cure  for,  244 
needle  forceps  used  for  repair- 
ing, 248 
operation,  after  treatment,  257 
Gosset's,  241 
Metzler's,  242 
method   of  uniting   edges, 

256 
Simon's.  252 
Sims's,  246 
physical  signs,  238 
prognosis,  238 

requiring  special  treatment,  261 
scissors  curved  for  paring  edges 

of,  246 
sinuses,   long,   tortuous,  capil- 
lary, remaining  after    opera- 
tion, treatment  of,  654 
Sims's  catheter  used  in,  251 
sutures,  mode  of  twisting,  250 

twisted.  251 
symptoms,  237 
treatment,  245 

by  cauterization,  244 
by  sutures,  245 

operation,  Sims's,  246 
approximating 
edges    and    se- 
curing sutures. 
250 
paring     edges    of 
fistula,  246,  247 
passing     sutures, 
248,  249 


Fistulae,  urinary,  operation — 

preparation  of  the 

patient,  245 
vivifying  edges  of, 
254,  255 
uretero-uterine,  263 
uretero-vaginal,  263 
urethro-vaginal,  234 
vagina,  closure  of,  259 
obliteration  of,  260 
vesico-uterine,  234,  261 
vesico-utero-vaginal,  234,  262 
vesico-vaginal,  233 
with    extensive   destruction    of 
the  base  of  the  bladder,  262 
Fistulae,  vesico-uterine,  261 
vesico-utero-vaginal,  262 
with   extensive   destruction   of  the 
base  of  the  bladder,  262 
Flexion  of  the  uterus,  influences  caus- 
ing, 378,   379  (see  Displace- 
ment of  the  uterus,  363) 
pathological  significance  of,  364 
varieties,  380 
Foetal  envelopes,  diseases  resulting  from 

retention  and  alteration  of,  602 
Follicular   degeneration   of    the   cervix 
uteri,  342  (see  Cystic  degeneration  of 
the  cervix  uteri). 
Follicular   vulvitis,   124    (see  Vulvitis, 

follicular). 
Food,  insufficient,  a  cause  of  disease,  51 
Forceps,  Nelaton's,  536 
Fossa  navicularis,  anatomy  of,  121 
Fungosities,  uterine,  346 
causes,  347 
course,  348 

curette,  dangers  of,  351 
definition,  346 
duration,  348 
frequency,  346 
history,  346 
pathology,  347 
physical  signs,  348 
prognosis,  349 
results,  349 
symptoms,  347 
synonyms,  346 
termination,  348 
treatment,  350,  634 
Fungous  degeneration    of    the    uterine 
mucous  membrane,  treatment  of,  634 


GALVANIC  pessary,  641 
(Jalvano-caustic    batterv,    Byrne's 

655 
Generative  organs,  development  of,  113 
Genital  track,  atresia  of,  and  retention  of 

menstrual  blood,  220 
"  Genu-pectoral"  position,  441 
Gland,  vulvo-vaginal,  cyst  and  abscess 

of,  126 
Glands,  Nabothian,  276 


INDEX. 


705 


Glandular  polypus,  559 
Gonorrhoea,  215 
causes,  215 
complications,  218 
definition,  215 
differentiation,  216 
duration,  217 
pathology,  215 
physical  signs,  216 
symptoms,  216 
terminations,  217 
"  Granular  cell"  of  Drysdale  in  ovarian 

fluid,  690 
Granular    degeneration    of    the   cervix 
uteri,  337 
causes,  exciting,  337 

predisposing,  337 
course,  339 
definition,  337 
duration,  339 
frequency,  337 
pathology,  339 
physical  signs,  339 
prognosis,  339 
symptoms,  338 
treatment,  339 
Granular  and  cystic  degeneration  of  the 
cervix  uteri,  336 
vaginitis,  218 
Growths,   intra-uterine,   ascertained  hy 

the  sound,  100 
Gynecology,  historical  sketch  of,  17 
list  of  journals  devoted  to,  40 
desirahle  works  upon,  39 
therapeutic  resources  of,  66 
diet,  66 
exercise,  66 
pessaries,  67 

precautions  for  preventing  sep- 
ticaemia and  py.emia  in  ope- 
rations, 70 
tampon,  77 

temperature,  means  of  control- 
ling, 78 
vaginal  injections,  74 


HABITUAL    constipation    a   cause    of 
disease,  52 
Haematocele,    pelvic,     509    (see    Pelvic 
hamiatocele). 
peritoneal,  513 
pudendal,  131 
causes,  133 
definition,  131 
development,   133 
natural  course,  134 
pathology,  132 
prognosis,  133 
symptoms,  133 
treatment,  134 
subperitoneal,  513 
Hemorrhage,  pudendal,  130 
causes,  131 


Hemorrhage,  pudendal — 
symptoms,  131 

treatment,  131 
Hernia,  pudendal,  134 
anatomy,  134 
causes,  135 
definition,  135 
symptoms,  135 
treatment,  135 
reclo-vaginal,  172 
vaginal,  173 

supplementary  support  in,  175 
surgical  procedures,  175 
treatment  of,  173 
Historical  sketch  of  gynecology,  17 
Hunter's  speculum,  97 
Hydatids,  uterine  604  (see  Uterine  hy- 
datids i. 
Hydrocele,  136 
anatomy,  136 
definition,  136 
differentiation,  137 
frequency,  136 
pathology,  136 
treatment,  138 
Hygiene  and  general  management,  in- 
attention to,  a  cause  of  failure  in  treat- 
ing uterine  disease,  64 
Hymen,  anatomy  of,  122 

causing  atresia  vaginae,  228 
imperforate,    causing    distention    of 

vagina  by  retained  blood,  224 
obstructive   dysmenorrhoea,    treat- 
ment of,  620 
Hyperesthesia  of  the  vulva,  145 
causes,  146 
definition,  145 
differentiation,  146 
frequency,  145 
pathology,  145 
symptoms,  146 
treatment,  146 
Hyperplasia,  areolar,  of  the  uterus,  307 
(see  Areolar   hyperplasia  of  the 
uterus), 
cervical,  of  the  uterus,  321 
Hysterotome,  Simpson's,  617 
Stohlman's,  618 
White's,  618 


IMPERFECT  diagnosis  in  uterine  dis- 
i.      eases,  a  frequent  cause  of  failure  in 

their  treatment,  62 
Inflammatory  ulceration  of  the  uterus, 

29 
Injections,  intra-uterine,  dangers  of,  302 
in  endometritis,  3U1 
vaginal,  74 
Inspection,  a  means  of  diagnosis,  90 
Insufficient  food  as  a   cause  of  disease 

among  women,  51 
Intestines,  prolapse  of,  173 
Intra-uterine  injections,  dangers  of,  302 


796 


INDEX, 


Intra-uterine  injections — 

important  facts  connected  with, 

305 
substances  used  for,  306 
Inversion  of  the  uterus,  453 
anatomy,  4">4 

amputation  of  the  uterus  for, 
methods  of,  471 
objections  to,  472 
causes,  exciting,  456 

predisposing,  456 
complete,  453 
course,  460 

cup  and  stem  for  gradual  re- 
duction, 465 
definition,  453 
differentiation,  459,  460 
duration,  460 

elastic    pressure    by   vaginal 
water-bag,  for  reducing,  466 
gradual  reduction  by  a  reposi- 

tor,  465 
methods    of   checking    hemor- 
rhage in,  462 
of  replacing,  463 
taxis  in,  467 

Barrier's,  469 
Courtey's,  469 
Emmet's,  469 
Noeggerath's,  469 
Thomas's,  469 
White's,  470,  471 
partial,  453 
pathology,  454 
physical  signs,  459 
prognosis,  461 
rapid  reduction  by  old  methods 

of  taxis,  467 
reduction  by  a  stream  of  cold 

water,  467 
symptoms,  458 
termination,  460 
treatment,  462 

resume  of  plans,  474 
varieties,  453 


JENKS'S  elastic  sound,  102 
Journals,  list  of,  devoted  to  gyneco- 
logy. 40 


IP'IFE,  Sims's,  431 
L     Kolpokleisis,  260 

LABIA  majora,  anatomy  of,  121 
phlegmonous    inflammation  of, 
12!) 
symptoms,  129 
treatment,  129 
Labia  minora,  anatomy  of,  121 
Lacerated    perineum,    dangers    arising 
from,  166 


Lacerated  perineum — 
effects  of,  165 
evils  arising  from,  167 
varieties,  186  (see  also  Rupture 
of  the  perineum),  182 
Laceration  of  the  cervix  uteri,  352 
anatomy,  353 
bilateral,  356 
causes,  354 
definition,  352 
denuded,  360 
differentiation,  358 
Emmet's  operation  for  repair  of, 

37 
frequency,  352 
history,  352 
pathology,  353 
physical  signs,  355 
prognosis,  359 
results,  358 
"stellate,"  357 

sutures  passed  in  operation  for, 
361 
twisted  in  operation  for,  362 
symptoms,  355 
synonyms,  353 
treatment,  359 
unilateral,  357 
varieties,  353 
Latero-fiexion,  452 
Leucorrhoea,  642 

cervical,   microscopical  appearance 

of,  645 
definition,  642 
frequency,  642 
history,  642 
pathology,  643 
prognosis,  645 
results,  645 
synonyms,  642 
treatment,  646 
vaginal,    microscopical   appearance 

of,  644 
varieties,  643 


MALFORMATIONS,  congenital  and  in- 
fantile, of  the  female  sexual  organs, 
112 
Mamma,    cancer   of,   stroma   and   cells, 

576,  577 
Management,  general  and  hygiene,  in- 
attention to,  a  cause  of  failure  in  treat- 
ing uterine  disease,  64 
Manikin  figure   for  teaching  diagnosis, 

112 
Manipulation,  conjoined,  88,  89 
Marriage  with  existing  uterine  disease  a 

cause  of  disease,  51 
Means  used   in  diagnosis  of  pelvic  dis- 
8,   111 

of  retaining  position  of  uterus  after 
anterior  displacements,  417,  418, 
419 


INDEX. 


707 


Menopause  a  cause  of  amenorrhcea,  C38    I 
Menorrhagia,  628 

causes,  029 
definition,  628 
differentiation,  G31 
frequency,  628 
pathology,  028 
prognosis,  032 
results,  032 
treatment,  032 
curative,  033 
Menstrual     blood,     retention     of,    etc., 

220 
Menstruation,  imprudence  during,  a  pro- 
lilic  source  of  disease  among  wo- 
men, 47 
tardy,  differentiated  from  amenor- 
rhea, 038 
Metalbumen,  test  for,  087 
Metritis,   chronic   parenchymatous,   307 
(see     Areolar     hyperplasia     of     the 
uterus). 
Metrorrhagia,  028 
causes,  629 
definition,  028 
differentiation,  031 
frequency,  028 
pathology,  028 
prognosis,  032 
results,  032 
treatment,  032 
curative,  033 
Microscope   as    a    means   of   diagnosis, 

109 
Misplacement  (congenital)  of  the  uterus, 

Hit 
Moles,  uterine,  002  (see  Uterine  moles). 
Moleswortlvs  cervical  dilators,  534 
Mucous  membrane,  cervical,  anatomy  of, 

276 
Myo-fibromata,  519  (see  Fibroid  tumors 
of  the  uterus). 


NABOTIIIAN  glands,  276 
Neck  of  the  uterus,  amputation  of, 

052  (see  Amputation  of  the  neck  of  the 

uterus). 
Needle-forceps  used  in  repairing  urinary 

fistulae,  24!) 
Needle  used  in  repairing  urinary  fistulae. 

249 
Neglect   or   non-recognition   of   injuries 

following  parturition,  a  frequent  cause 

of  disease  in  women,  50 
Nelaton's  forceps  for  removal  of  uterine 

fibroids,  535 
Neurasthenia,  Weir  Mitchell's  treatment 

for,  330 
Non-recognition   or   neglect   of  injuries 

due  to  parturition   a  frequent   cause 

of  disease  among  women,  49 
Nott's  speculum,  97 


a  EDEMATOUS    elongation    with    pro- 
J     lapse  of  the   neck  of  the   uterus, 
390 
Ointments,  use  of,  in  chronic  corporeal 

endometritis,  300 
Oophorectomy,  756 

estimate  of  operation,  759 

history,  750 

indications,  757 

means    of  treatment  of   uterine 

fibroids,  as  a,  551 
methods  of  operating,  758 
names  of  operators,  758 
results,  757 
synonyms,  750 
theory  of  operation,  756 
Ovarian  apoplexy,  003 
definition,  003 
prognosis,  004 
symptoms,  004 
treatment,  004 
Ovarian  cysts  and  cystomata,  682 
aspiration  in,  715 
broad  ligaments,  cysts  of,  696 
causes,  691 
chemical   constituents   of  fluid 

from,  686 
conditions  likely  to  complicate, 
695 
simulating,  705 
contents  of,  680 
cure,  spontaneous,  of,  694 
death,  methods  by  which  pro- 
duced, 095 
diagnosis,  rules  for,  721 
differentiation    from    abnormal 
thickness    or   tension   of 
the  abdominal  walls,  700 
from  cystic  disease  of  other 
parts    of    the   abdomen, 
709 
from  diseased  states  of  the 
pelvic  walls  and  areolar 
tissue,  712 
from  distention  of  abdomi- 
nal viscera,  700 
Irom  excessive  development 
or  displacement  of  other 
viscera,  711 
from  fluid  peritoneal  accu- 
mulations, 707 
from  fibrocyst,  uterine,  710 
from  pregnancy,  711 
diseased    conditions    affecting, 

094 
"does  a  tumor  exist  ?"  701 
explorative  incsion  in,  720 
fluid,  microscopical  appearance 

of,  088,  089 
"agranular   cell"    of  Drysdale, 

690 
hydatid  cysts,  098 
"is  the  tumor  ovarian  ?"  702 
meltalbumen,  test  for,  687 


798 


INDEX. 


Ovarian  cysts  and  cystomata — 

microscopical   investigations  of 

Noeggerath,  685 
natural  history  of,  693 
paralbumen,  test  for,  G87 
pathological  processes  in,  gene- 
ration of,  083 
pedicle  in,  long,  713 
short,  714 
twisted,  714 
physical  exploration,  means  of, 
702 
signs,  701 
spinal    cord,    cysts    connected 

with,  699 
subperitoneal  cysts,  699 
symptoms,  699 

table  showing  comparative  fre- 
quency of  affection  of  right 
and  left  ovary,  686 
tapping  in,  716 

through  abdomen,  718 
through  vaginal  wall,  719 
treatment,  721 
tubal  dropsy,  697 
Ovarian  disease  a  cause  of  symptoms  of 
uterine  disease,  33 
fluids,  microscopical  appearance  of, 
688 
Ovarian  tumors,  672 

carcinoma,  673 
colloid,  680 
cysto-carcinoma,  676 
cysto-fibroma,  677 
cysto-sarcoma,  677 
dermoid  cysts,  679 
fibroma,  675 

malignant,  symptoms  of,  674 
table  of,  673 
Ovaries,  absence  of,  660 

and  rudimentary  development 
of,  115 
state  of,  119 
atrophy  of,  662 
Ovaries,  diseases  of,  656 
absence  of,  660 
anatomy,  658 
atrophy  of,  causes,  662 

treatment,  663 
development,  imperfect,  of,  660 

treatment  of,  661 
displacement  of,  664 

treatment,  665 
history,  656 

ovarian  apoplexy,  663  (see  Ova- 
rian apoplexy), 
ovaritis.  665 

definition  of,  665 
treatment  of,  665 
acute,    666    (see   Ovaritis, 

acute), 
chronic,  669   (see  Ovaritis, 
chronic). 
Tilt's  views  upon,  34 


Ovaries,  diseases  of — 
varieties,  660 
Ovariotomy,  722 
abdominal,  733 

conditions   favorable    to  operation, 
728 
unfavorable,  730 
dangers,  727 
definition,  722 
"fever   cot,"   Kibbee's,    after,  752, 

753 
history,  722 

injections,  antiseptic,  after,  750 
operation,  after-treatment,  747 
steps  of,  734 

applying  antiseptic  dress- 
ing, 746 
cleansing  peritoneum,  744 
closing  abdominal  wound, 

746 
drainage  (if  necessary),  es- 
tablishing, 745 
incision  through  abdominal 

walls,  734 
removal  of  sac,  738 
securing  pedicle,  740 
tapping  tumor,  737 
peritonitis  after,  751 
septicaemia  following,  748 

methods  of  avoiding,  748 
statistics,  728 
sutures,  removal  of,  after  operation, 

755 
temperature  after,  749 
vaginal,  731 
varieties,  727 
Ovaritis,  665 

definition,  665 
varieties,  665 
Ovaritis,  acute,  666 
causes,  668 
differentiation,  668 
prognosis,  668 
symptoms,  668 
treatment,  668 
Ovaritis,  chronic,  669 
prognosis,  671 
signs,  physical,  670 

rational,  670 
treatment,  671 
Ovary,  carcinoma  of,  673 

colloid  degeneration  of,  680 
cysto-carcinoma  of,  776 
cysto-fibroma  of,  677 
cvsto-sarcoma  of,  677 
cysts  (dermoid)  of,  679 
fibroma  of,  675 
fibrous  tumors  of,  675 


PALPATION,  abdominal,  89 
conjoined  with  the  use  of  the 
sound,  90 
bimanual,  88 


INDEX. 


799 


Papillae,  filiform,  of  the  vagina,  212 
Paquelin's  thermo-cautery,  149,  535 
Paralbumon,  test  for,  o'>S7 
Parturition,  imprudence  after,  a  frequent 

cause  of  disease  among  women,  48 
Pathological  views  of  uterine  disorders, 
29 
displacements,  32 
Pathology  and  treatment,  uterine,  gen- 
eral considerations  upon,  54 
Pean's  operation  for  removal  of  uterine 

fibroid  tumors,  548 
Pelvic  abscess,  502 

causes,  502 

closure  of  sac,  means  for  caus- 
ing, 508 

course,  503 

definition,  502 

differentiation,  503 

duration,  503 

evacuation,  best  point  for,  507 

operating,  methods  of,  507 

pathology,  502 

physical  signs,  503 

prognosis,  504 

puncture  per  vagina,  507 

routes  for  discharge  of,  503 

sac,  means  of  closure  of,  507 

symptoms,  502 

termination,  503 

treatment,  504 
Pelvic  hematocele,  509 

causes,  512 

course,  51b' 

definition,  509 

differentiation,  515 

duration,  516 

frequency,  510 

history,  509 

operating  in,  methods  of,  518 

pathology,  510 

peritoneal,  513 

physica1  signs,  515 

prognosis,  516 

reflux  of  blood  from  the  uterus, 
511 

rupture  of  bloodvessels  in  the 
pelvis,  510 
of  pelvic  viscera,  511 

subperitoneal,  513 

symptoms,  514 

synonyms,  509 

termination,  516 

transudation  from  bloodvessels, 
511 

treatment,  517 

varieties,  512 
Pelvic  peritonitis,  487 

cases,    chronic,    treatment    of, 
500 

causes,  491 

course,  496 

definition,  487 

differentiation,  476 


Pelvic  peritonitis — 

duration,  496 

evacuation  of  pus  and  serum, 

modi's  of,  501 
frequency,  490 

history,  478 

importance    of     differentiation 

from  pelvic  cellulitis,  498 
pathology,  490 
physical  signs,  495 
prognosis,  498 
results,  498 

"roof  of  the  pelvis,"  490 
symptoms,  493 
termination,  496 
treatment,  498 
varieties,  493 
Pelvis,  roof  of  the,  490 
Percussion  and  auscultation  as  a  means 

of  diagnosis  in  pelvic  disease,  111 
Perineal  body,  158,  182 
anatomy,  183 

descent   of   rectal    and    vesical 
walls    after    destruction    of, 
419 
diagrams  of,  160,  161,  163, 183, 

184 
surgical  means  for  the  restora- 
tion of,  182 
Perineal  laceration,  187 
causes,  187 

natural  history  of,  187 
operation,  denudation  for  repair 
of,  194 
diagrams  of  "triangle"  to 

be  united,  195 
first  part  of,  192 
instruments  and  appliances 

needed  for,  191 
preparation  of  the  patient, 

191 
schematic  view  of  part  to 

be  denuded,  193 
for  complete,  198 

denuded    surface    and 
sutures  (diagram of) 
201 
diagrams,  198, 199,200 
rules  to  be  observed  in, 
.     201 
for  partial,  192 

dentist's  "  burr"  used 

in,  196 
method     of     securing 
ends      of      sutures, 
198 
profile  view  of  recently 
closed  perineum  and 
sutures,  198 
surface   denuded    and 
sutures    in.  position 
(diagrams),  197 
prognosis,  187 
time  for  operation,  188 


800 


INDEX. 


Perineal  laceration — 

treatment  of  cases  which  have 

cicatrized,  190 
varieties,  186 
Perineal  support  in  prolapsus  of  the  ute- 
rus, 404 
Perineorrhaphy  in  cases  of  prolapsus  of 

the  uterus,  404 
Perineum,  154 
anatomy,  154 
diagram  of,  156 
functions  of,  159 
physiology  of,  159 
improperly  repaired,  185 
Perineum,  laceration  of,  165 

dangers    arising    from,    166, 

167 
effects,  165 
varieties,  186 
Perineum,  profile  view  of,  192 
rupture  of,  165 
subinvolution  of,  164 
Peritoneal  hematocele,  513 
Peritonitis,  pelvic,  487  (see  Pel  pic  peri- 
tonitis). 
Periuterine  cellulitis,  475 
anatomy,  476 
causes,  481 
complications,  477 
consequences,  4S5 
course,  480 
definition,  476 
differentiation,  484 
duration,  480 
frequency,  476 
history,  475 
pathology,  477 
physical  signs,  483 
prognosis,  481 
symptoms,  482 
synonyms,  476 
termination,  480 
treatment,  485 
Pessaries  in   anterior  displacements  of 
the   uterus,  420,  421,  422,   423, 
425,  428,  429 
in  prolapsus  of  the  uterus,  401 
Pessary,  Albert  Smith's,  446 

Campbell's  soft-rubber,  spring-stem, 

'429 
Cutter's  "  T,"  for  anterior  displace- 
ments, 423 
prolapsus,  403 

modification  of,    with    cervical 
rest,    for   posterior   displace- 
ments, 451 
retroversion,  449 
elastic  bulb,  447 
Fowler's,  for  anterior  displacements, 

425 
galvanic,  461 
Hewitts,  448 

anteversion,  424 
Hodge's  closed  lever,  445 


Pessary — 

Hoffman's   inflated   soft-rubber,  for 

posterior  displacements,  444 
Hurd's,  447 

intra-uterine  stem  for   anteflexion, 
428 
glass  stem  for  anterior  displace- 
ments, 428 
latero-flexion,  for,  452 
Meigs's  elastic  ring,  447 
retroflexion,  with  cervical  rest,  451 
Thomas's    anteversion,    with   fixed 
projection,  442 
elastic,    for    anterior  displace- 
ments, 422 
modification   of  Cutter's,   403, 
423 
for  posterior  displace- 
ments, 449 
retroflexion,  446 
Phlegmonous  inflammation  of  the  labia 
majora,  129 
symptoms,  129 
treatment,  129 
Physical  signs  of  uterine  disease,  59 
Polypi,  uterine,  558  (see  Uterine  polypi) 
Polyptome,  Aveling's,  535 

Simpson's,  564 
Polypus,  causing  obstructive  dysmenor- 
rhoea,  treatment,  620 
cellular,  559 
fibroid,  560 
glandular,  559 

differentiation  from  inverted  uterus, 
459 
Position,  "genu-pectoral,"  441 

of    patient  for   introducing   Sims's 
speculum,  99 
Posterior  displacements  of  the  uterus, 
432 
causes,  exciting,  434 

predisposing,  434 
consequences  of,  438 
definition,  432 
differentiation,  437 
forces     applied    in    reduction, 

450 
frequency,  432 

"genu-pectoral"  position,  441 
Hoffman's  inflated    soft-rubber 

pessary  in,  444 
means   of  retaining   uterus  in 

position.  442 
methods  of  reduction,  438 
pessaries,  444,  445,   446,  447, 

448,  449,  451 
physical  signs,  437 
prognosis,  438 
retroversion,  degrees  of,  436 
Sims's  uterine  repositor,  440 
symptoms,  436 
tampon  in,  443 
treatment,  438 
varieties  of  retroversion,  435 


INDEX. 


801 


Posture,  recumbent,  in  prolapsus  of  the 

uterus,  o'.,s 
Pregnancy,  extra-uterine,  70;">  (see  Kx- 

tra-uterine  pregnancy). 
Primary  pathological  conditions  produc- 
ing utering  disease,  57,  58 
Probe,  Budd's  elastic,  280 

Lente's  silver  caustic,  2S7 
silver,  finis's,    for   applying  medi- 
cated cotton  to  cervix  uteri,  288 
Thomas's  flat  elastic  whalebone,  540 
Probing  the  uterus,  method  of,  101 
Prognosis,  erroneous,  a  frequent  cause  of 
failure  in  treating  uterine  disease;, 
02 
in  uterine  affections,  (50 
Prolapse  of  the  bladder,  172 

of  the  intestines,  173 
Prolapsus  urethras,  150 
treatment,  150 
Prolapsus  of  the  uterus,  381 
acute,  394 
anatomy,  382 
astringents  in  the  treatment  of, 

398 
causes,  383 
complications,  393 
course,  390 
definition,  381 

diagrams  of,    in  the  three  de- 
grees of,  383 
diaphragm,   action  of  the,   in, 

400 
differentiation,  392 
duration,  390 
episiorrhaphy  for,  405 
frequency,  381 

means     to     diminish     uterine 
weight,  398 
to   prevent   pressure  from 

above,  397 
to  prevent  traction  by  the 

vagina,  40-1 
to   strengthen    or    supple- 
ment   uterine  supports, 
398 
methods  of  replacing,  394 

of  sustaining,  395 
oedematous     elongation,      with 

prolapse  of  the  neck,  390 
pathology,  385 
perineal  support,  404 
perineorrhaphy,  404 
pessaries,  401 
physical  signs,  392 
posture,  recumbent,  in,  398 
prognosis,  392 
sudden,  394 
symptoms,  391 
synonyms,  381 
termination,  390 
tonics  in  the  treatment  of,  398 
treatment,  394 
varieties,  383 
51 


Prolapsus  of  the  vagina,  1G8 

causes,  170 

course,  171 

definition,  107 

duration,  171 

pathology,  170 

prognosis,  171 

symptoms,  171 

synonyms,  109 

treatment,  171 

varieties,  171 
Pruritus  vulva?,  138 

causes,  exciting,  140 
predisposing,  139 

course,  138 

definition,  138 

development,  138 

pathology,  138 

treatment,  141 
Pubo-coccygeus  muscle,  204 
Pudendal  hematocele,  131 

causes,  133 

definition,  131 

development,  133 

history,  132 

natural  course,  134 

pathology,  132 

prognosis,  133 

symptoms,  133 

treatment,  134 
Pudendal  hemorrhage,  130 

causes,  131 

symptoms,  131 

treatment,  131 
Pudendal  hernia,  134 

anatomy,  134 

causes,  135 

definition,  135 

symptoms,  135 

treatment,  135 
Purulent   vulvitis,    122    (see   Vulvitis, 

purulent). 
Pyaemia    and    septicaemia,    precautions 
against,  in  operations,  70 


REASONS  for  the  frequency  of  failure 
in  the  treatment  of  uterine  diseases, 
01 

Recamier's  speculum,  25 

Recapitulation  of  means  used  in  diag- 
nosis of  pelvic  disease,  111 

Rectal  touch,  91 

Rectocele,  172 

Recto-vaginal  hernia,  172 

Rectum,  prolapse  of,  172 

Relation  between  uterine  disease  and 
constitutional  depreciation,  31 

Retroflexion  of  the  uterus,  432,  433  (see 
Posterior  displacements  of  the  uterus) . 

Retroversion  of  the  uterus,  432,  433  (see 
Posterior  displacements  of  the  uterus). 

Rod  for  making  applications  to  cervix 
uteri,  285 


802 


INDEX. 


Rudimentary  state  and  absence  of  the 
ovaries,  lilt 
of  the  vagina,  119 
Rules  for  the  introduction  of  tents,  108 


SALPINGITIS,  762 
Sarcoma  of  the  uterus,  566 
causes,  569 
course,  570 
definition,  567 
differentiation,  570 
duration,  570 
frequency,  567 
history,  566 
pathology,  567 
physical  signs,  569 
prognosis,  570 
symptoms,  569 
synonyms,  567 
termination,  570 
treatment,  570 
Scarificator,  Buttles's  spear-pointed,  333 
Schroeder's  operation  for  removal  of  ute 

rine  fibroid  tumors,  549 
Scissors,  sharply  curved,  Emmet's,  192 

slightly  curved,  191 
Scoop,    Simon's,   for    removing    cancer, 

595 
Screw  for  removing  tampon,  Sims's,  78 
Sea-tangle  tents,  103 

advantages  of,  104 
Septicaemia    and    pyaemia,    precautions 

against,  in  operations,  70 
Sigmoid  catheter,  Sims's,  251 
Signs,  physical,  of  uterine  disease,  59 
Simon's   operation   for  urinary  fistulae, 
252 
advantages  of,  254 
position  of  patient  in,  253 
Sims's  operation  for  urinary  fistulae,  246 
speculum,  37 

advantages  of,  37 

an  era  in  gynecology,  35 

(and  varieties  of)  introduction 

of,  98 
position  of  patient  in  introduc- 
tion, 99 
Sinuses,   treatment   of    long,    tortuous, 
capillary,  remaining  after  operation, 
264 
Skirt  supporter,  397 
Sound,  uterine,  as  a  means  of  diagnosis, 
100 
difficulties  and  dangers  attend- 
ing its  use,  100 
facts  ascertained  by,  100 
Jenks's  elastic,  102 
Jennison's,  415 
method  of  introduction,  100 
passage  of,  in  amenorrhea,  640 
Simpson's     and     Sims's,     con- 
trasted, 101 
used  by  the  anoients,  24 


Specula,  ancient,  23 

valvular  and  cylindrical,  method  of 
introduction,  98 
Speculum,  bivalve,  23 
Cusco's,  94 
Fergusson's,  93 

Howard's  modification  of  Cusco's,  95 
Hunter's,  97 

invented  by  R^camier,  25 
mentioned  by  ancient  writers,  24 
Neugebauer's,  95 
Nott's,  97 
Sims's,  96 

advantages  of,  37 

an  era  in  gynecology,  35 

(and  varieties  of)  introduction 

of,  98 
Thomas's  modification  of,  97 
Thomas's  telescopic,  94 
trivalve,  23 
Wylie's  cervical,  299 
Spinal  cord,  cysts  connected  with,  699 
Sponge-holder,  Sims's,  247 
Sponge-tents,  103 
Spoon-saw,    Thomas's,   for    removal    of 

uterine  fibroids,  539 
Sterility,  648 
causes,  648 
definition,  648 
differentiation,  651 
history,  648 
prognosis,  651 
results,  651 
synonyms,  648 
treatment,  651 
Stricture  of  Fallopian  tubes,  763 
Subperitoneal  hematocele,  513 
Symptoms  of  uterine  disease  dependent 

on  ovarian  disease,  33 
Syphilitic  ulcer  of  the  cervix  uteri,  344 
course,  345 
differentiation,  345 
frequency,  344 
termination,  345 
treatment,  345 
Syringe,  Davidson's,  76 

for  dry  cupping  the  cervix,  640 
for  removing  cervical  mucus,  284 
Molesworth's    double    canula    and 
bulb    for   injecting    the    uterine 
cavity,  306 
vaginal,   nozzle   with   reverse   cur- 
rent, 76 


TABLE,    gynecological,  Thomas's,    85, 
86 
Tampon,  77 

in   posterior   displacements   of   the 
uterus,  443 
Taxis,  old  methods  for  replacing  inverted 

uterus,  467 
Taxis,   rapid  reduction  of  inversion  of 
uterus  by, 


INDEX. 


803 


Taxis,  rapid  reduction  of  inversion  by — 
Barrier's  method,  469 
Courty's  method,  409 
Emmet's  method,  469 
Noeggerath's  method,  4G9 
Thomas's  method,  409 
White's  method,  470,  471 
Tenaculum  for  fixing  the  uterus,  106 
Tent,  Wallace's  spring,  416 
Tents,  102 

dangers  of  using,  106 
in  amenorrhcea,  640 
method  of  introduction,  105 
rules  for  the  introduction  of,  108 
sea-tangle,  103 
sponge,  103 
tupelo,  105 
Therapeutic    resources   of    gynecology, 
diet  and  exercise,  66 
pessaries,  67 

precautions  for  preventing  sep- 
ticaemia andpysemia  in  ope- 
rations, 70 
tampon,  77 

temperature,  means  of  control- 
ling after  operation,  78 
vaginal  injections,  74 
Therapeutics,    inefficient     or      inappro- 
priate, a  cause  of  failure  in  treating 
uterine  disease,  62 
Thermo-cautery,  Paquelin's,  149 

incision  of  the  cervix  uteri  by,  535 
Thomas's  operation  for  removal  of  ute- 
rine fibroid  tumors,  549 
Tight    bandaging   a   cause    of    disease 

among  women,  48 
Tilt's  views  on  ovarian  disease,  34 
Tonics,  in  the  treatment  of  prolapsus  of 

the  uterus,  398 
Toothed  forceps,  Thomas's,  191 
Trivalve  speculum,  23 
Trocar  and  canula,  Emmet's,  for  tapping 
cysts,  737 
for  tapping  ovarian  cysts,  719 
Tubal  dropsy,  697,764 
Tumors  of  the  external  organs  of  gene- 
ration, 154 
Tumors,  fibrocystic,  of  the    uterus,  551 
(see     Fibrocystic   tumors    of   the 
uterus), 
fibroid  of  the  uterus,  519  (see  Fibroid 

tumors  of  the  uterus), 
ovarian,  672  (see  Ovarian  tumors), 
uterine,  differentiation  of,  from  dis- 
placements,   by  the   use    of  the 
sound, 100 
Tupelo  tents,  105 


ULCER,  syphilitic,  of  the  cervix  uteri, 
344    (see    Syphilitic   ulcer   of   the 
cervix  uteri). 
Ulcers  of  the  uterus,  Astruc  on,  26 
Ulcerations  of  the  uterus,  cancerous,  29 


Ulcerations  of  the  uterus — 
inflammatory,  29 
Unicorn  uterus,  118 
Urethra;,  prolapsus,  150 
treatment,  150 
Urethral  caruncle,  irritable,  147 
causes,  147 
course,  148 
differentiation,  148 
duration,  148 
pathology,  147 
physical  signs,  148 
prognosis,  148 
treatment,  148 
Urethral  venous  angioma,  150 
Urethro-vaginal  fistula),  234 
Urinary  fistula;,  233  (see  Fistulae,   uri- 
nary). 
Uteri,  cervix,  cystic  degeneration  of,  342 
causes,  343 
definition,  342 
pathology,  343 
prognosis,  343 
synonyms,  343 
treatment,  343 
Uteri,  cervix,  granular  degeneration  of, 
337 
causes,  exciting,  337 

predisposing,  337 
course,  339 
definition,  337 
duration,  339 
frequency,  337 
patholagy,  339 
physical  signs,  339 
prognosis,  339 
symptoms,  338 
treatment,  339 
Uteri,    cervix,    laceration   of,    352   (see 
Laceration  of  the  cervix), 
syphilitic  ulcer  of,  344  (see  Syphi- 
litic ulcer  of  the  cervix). 
Uterine  adenoma,  570  (see  Sarcoma  of 
the  uterus), 
atresia  at  os  externum,  223 
at  os  internum,  223 
in  one  half  of  a  double  uterus, 
223 
canal,  deviations  of,  determined  by 

the  sound,  100 
cancer,  571  (see  Cancer  of  the  ute- 
rus), 
cavity,  applications    to,  in    chronic 
corporeal  endometritis,  298 
injections   into,  in  chronic  cor- 
poreal endometritis,  301 
development  in  childhood,  anoma- 
lies of,  119 
disease  in  its  relations  to  constitu- 
tional depreciation,  31 
physical  signs  of,  59 
primary  pathological  conditions 

causing,  57,  58 
prognosis  in,  60 


804 


INDEX. 


Uterine — 

disorders,     different      patfiological 

views  on,  29 
displacements,  differentiation  from 
tumors  by  the  sound,  100 
pathological  views  upon,  32 
primary  factors  in  uterine  dis- 
ease, 33 
fibromata,  522 
fungosities,    346  (see    Fungosities, 

uterine), 
hydatids,  604 
causes,  605 
definition,  604 
differentiation,  606 
pathology,  604 
physical  signs,  605 
prognosis,  606 
symptoms,  605 
synonyms,  604 
treatment,  506 
moles,  602 

causes,  603 
definition,  602 
differentiation,  603 
history,  602 
pathology,  602 
physical  signs,  603 
prognosis,  604 
symptoms,  603 
treatment,  604 
pathology   and  treatment,  general 

considerations  upon,  54 
polypi,  558 

causes,  560 

cellular,  559 

complications,  562 

course,  562 

definition,  558 

differentiation,  561 

<5craseur,    Hicks's    wire    rope, 

565 
fibrous,  560 
glandular,  560 
history,  558 

pathological  anatomy,  559 
physical  signs,  561 
polyptome,  Aveling's,  535 

Simpson's,  564 
prognosis,  562 
symptoms,  560 
termination,  562 
treatment,  562 
curative,  563 
palliative,  563 
varieties,  558 
repositor,  Elliot's,  415 

Sims's.  440 
sarcoma,  566   (see   Sarcoma   of  the 

uterus). 
sound,  difficulties   and  dangers  at- 
tending the  use  of,  100 
facts  ascertained  by,  100 
means  of  diagnosis,  as  a,  100 


Uterine  sound- 
method  of  introduction,  100 
Simpson's     and     Sims's    con- 
tracted, 101 
used  by  the  ancients,  24 
Uterus,  ablation  of,  545  (see  Ablation  of 
the  uterus). 

absence  and  rudimentary  develop- 
ment of,  115 

amputation  of  the  neck  of,  652  (see 
Amputation  of  the  neck  of  the 
uterus). 

anteflexion  of  the,  410  (see  Ante- 
flexion of  the  uterus). 

anteversion  of  the,  405  (see  Ante- 
version  of  the  uterus). 

areolar  hyperplasia  of,  307  (see  Are- 
olar hyperplasia  of  the  uterus). 

atresia  of,  221  (see  Atresia  of  the 
uterus). 

axes  of  the,  in  anteflexion,  411,  430 

bicorn,  118 

cancer  of  the,  571 

early  views  on,  26 

capacity  of,  ascertained  by  use  of  the 
sound, 100 

congenital  misplacement  of  the, 
119 

divided,  118 

double,  118 

extirpation  of  the,  545 
for  cancer,  598 

inflammation  of,  J.  H.  Bennet's  views 
on,  28 

inflammatory  ulcerations  of,  29 

inversion  of,  453  (see  Inversion  of 
the  uterus). 

method  of  probing,  101 

mobility  of,  determined  by  the 
sound,  100 

natural  position  of,  366,  368 

pathological  significance  of  versions 
and  flexions  of  the,  364 

prolapsus  of  the,  381  (see  Prolapsus 
of  the  uterus). 

retroflexion  of  the,  432,  433  (see 
Posterior  displacements  of  the 
uterus). 

retroversion  of  the,  432,  433  (see 
Retroversion  of  the  uterus). 

ulcers  of  the,  Astruc  on,  26 

unicorn,  118 
Uterus  and  ovaries,  absence  and  rudi- 
mentary development  of,  115 

and  vagina,  distended  with  blood 
from  imperforate  hymen,  224 


VAGINA,    absence    and    rudimentary 
state  of,  119 
anatomy  of,  211 
atresia  of,  224  (see   Atresia  of  the 

vagina). 
closure  of,  treatment  for,  229 


INDEX. 


805 


Vagina — 

distended  by  blood  from  imperforate 

hymen,  224 
filiform  papillae  of,  212 

prolapsus  of,  168 

causes,  170 

course,  171 

definition,  167 

duration,  171 

pathology,  170 

prognosis,  171 

symptoms,  171 

synonyms,  169 

treatment,  171 

varieties,  171 
transverse  section  of,  If  7 
Vagina  and  uterus  distended  with  blood 

from  imperforate  hymen,  224 
Vaginal  dilator,  Sims's,  207 

hernia,  supplementary  support  in, 
175 

surgical  procedures,  175 
leucorrhoja,    microscopical    appear- 
ance of,  644 
ovariotomy,  731 
prolapse,  treatment  of,  174 
Vaginal  stricture,  treatment  of,  620 
touch, 87 

water-bag   for    elastic    pressure    in 
inverted  uterus,  466 
Vaginismus,  203 
anatomy,  204 
causes,  205 
course,  206 
definition,  203 
differentiation,  206 
duration,  206 
frequency,  203 
history,  204 
operation,  Sims's,  209 

Burns's,  210 
pathology,  204 
physical  signs,  206 
prognosis,  206 
symptoms,  206 
treatment,  207 
Vaginitis,  211 

anatomy  of  vagina,  211 
definition,  211 
epithelium  in,  214 
granular,  218 

causes,  219 

definition,  219 

pathology,  218 

symptoms,  219 

synonyms,  218 

treatment,  219 
simple,  212 

causes,  213 

complications,  215 

definition,  212 

differentiation,  215 

pathology,  213 

physical  signs,  214 


Vaginitis,  simple — 

symptoms,  214 
specific,  215 

causes,  215 
complications,  218 
definition,  215 
differentiation,  216 
duration,  217 
pathology,  215 
physical  signs,  216 
symptoms,  216 
termination,  217 
synonyms,  211 
treatment  of,  219 
varieties,  212 
Valvular  and  cylindrical  specula,  method 

of  introduction,  98 
Venous  angioma,  urethral,  150 
Versions  of  the  uterus,  pathological  sig- 
nificance of,  364 
Vesico- vaginal  fistulae,  233  (see  Fistula;, 

urinary). 
Vesico-uterine  fistula?,  234 
Vesico-utero-vaginal  fistulse,  234 
Vestibule,  anatomy  of,  121 
Villi  of  canal  of  cervix  uteri,  276 
Vulva,  diseases  of,  121 

eruptive  diseases  of,  128 

treatment,  129 
hypersesthesia  of,  145 
causes,  146 
definition,  145 
differentiation,  146 
frequency,  145 
pathology,  145 
symptoms,  146 
treatment,  146 
Vulvae,  pruritus,  138 

causes,  exciting,  140 
predisposing,  139 
course,  138 
definition,  138 
development,  138 
pathology,  138 
treatment,  141 
Vulvitis,  definition,  122 
follicular,  124 
causes,  124 
course,  125 
definition,  124 
duration,  125 
physical  signs,  125 
symptoms,  125 
synonyms,  124 
treatment,  125 
purulent,  122 
causes,  123 
course,  123 
symptoms,  123 
termination,  123 
treatment,  123 
varieties  of,  122 
Vuivo-vaginal  glands,  abscess  and  cyst 
of,  126 


806 


INDEX. 


Vulvo-vaginal  glands — 
anatomy  of,  126 
inflammation  of,  127 
causes,  127 
course,  127 
differentiation,  127 
duration,  127 
symptoms,  127 
treatment,  127 


WAIST  for  supporting  skirts,  397 
Water-bed,  Kibbee's  752,  753 
Water,  stream  of  cold,  for  replacing  in- 
verted uterus,  467 
Women,  etiology  of  diseases  peculiar  to, 

41 
Works  on  gynecology,  list  of,  40 


IRISHMAN'S  MIDWIFERY— Just  Ready. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF  PREGNANCY  AND 

THE  PUERPERAL  STATE.     By  William  Leisiiman,  M.D.,  Regius  Professor  of 

Midwifery  in  the  University  of  Glasgow,  etc.      Third    American    edition,  revised 

by  the    author,   with  additions  by  John  S.  Pakry,  M.D.,  Obstetrician  to  the  Philn. 

Hospital,  etc.     In  one  large  and  very  handsome  octavo  volume  of  TA'.\  pages,  with 

,  over    200  illust.     Cloth,  $4  50,   leather,  $5  50;   very  handsome  half  Russia,  raised 

bands,  $6. 

We  gladly  weloome  the  new  edition   of  this    ommending  it.     Asan  exponontof  the  midwifery 

excellent  text-book  of  midwifery.     The  former  \  of  the  present  day  it  has  no  superior  in  the  cng- 

editlons  have   been  mott  favorably  received  by  ;  lish  language.  —Canada  Lancet,  Jan.  18b0. 

the  profession  ou  both  side*  of  the  Atlantic.    In  I      To  the  American  student  the  work  before  us 

the  preparation  of  the  present  edition  the  author     raust  prove  admirably  adapted,  complete  iu  all 


lids  made  .such  alterations  as  the  progress  of  ob- 
Btetrlcal  scieuce  seems  to  require,  aud  we  cannot 
but  admire  the  ability  wi  h  which  the  task  has 
been  performed.  We  consider  it  an  admirable 
text-book  for  students  dining  their  attendance 
upou  lectures,  and  have  great  pleasure  in  rec- 


its  parts,  essentially  modern  iu  its  teachings  and 
with  demonstrations  noted  tor  clearness  and 
precisian,  it  will  gain  in  favor,  and  be  recognized 
as  a  work  of  standard  merit.  The  work  cannot 
fail  to  be  popular,  and  is  cordially  recommended. 
— N.  0.  Mad.  and  Swry.  Juurn  ,  March,  lbSO. 


PLAYFAIR'S  MIDWIFERY— Just  Ready. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY.  By  W.  S. 
Playfair,  M.D.,  F.R.C.P.,  Professor  of  Medicine  in  King's  College,  etc.  Ed- 
ited, with  additions,  by  Robert  P.  Harris,  M.  D.  In  one  handsome  octavo  vol- 
ume of  about  700  pages,  with  nearly  200  illustrations.  Cloth,  $4;  leather,  $5  ;  very 
handsome  half  Russia,  raised  bands,  $5  50. 

The  rapidity  with  which  one  edition  of  this  It  certainly  is  an  admirable  exposition  of  the 
work  follows  another  is  proof  alike  of  its  excel-  Science  and  Practice  of  Midwifery.  Of  course 
leuce  and  of  the  estimate  that  the  profession  has  the  additions  made  by  the  American  editor,  Dr. 
formed  of  it.  It  is  indeed  so  well  known  and  so  K.  P.  Harris,  who  never  utters  an  idle  w  ord,  and 
highly  valued  that  nothing  nted  be  said  of  it  as  i  whose  studious  researches  in  some  special  de- 
a  whole.  All  things  considered,  we  regard  this  j  partments  of  obstetrics  are  so  well  known  to  the 
treatise  as  the  very  best  ou  Midwifery  in  the  I  profession,  are  of  great  value. —  The  Am.  Prac- 
English language.—  N.  Y.  Med.  Juurn.,  May,  1S80.  j  titioner,  April,  ISso. 

HODGE'S  OBSTETRICS. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS  By  Hugh  L.  Hodge,  M.D., 
Emeritus  Professor  of  Midwifery  in  the  University  of  Pennsylvania.  Illustrated 
with  large  lithographic  plates,  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully 
printed  quarto  vol.  of  550  double-columned  pages  strongly  done  up  in  cloth.  $14. 
*;;;«■  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address  free,  by 

mail,  on  receipt  of  six  cents  in  postage  stamps. 


HODGE  ON  DISEASES  OF  WOMEN. 

ON  DISEASES  PECULIAR  TO  WOMEN  :  Including  Displacements  of  the  Uterus  By 
Hugh  L.  Hodge,  M.D.,  Emeritus  Professor  of  Oostetrics  in  the  Univ.  of  Penna. 
With  original  illustrations.  Second  edition,  revised  and  enlarged.  In  one  octavo 
volume  of  o31  pages.     Cloth,  $4  50. 


RAMSBOTHAM'S  MIDWIFERY. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND  SURGERY, 
in  reference  to  the  Process  of  Parturition.  By  Francis  H.  Ramsisotham,  M.D.  A 
new  and  enlarged  edition,  thoroughly  revised  by  the  author.  With  additions  by 
W.  V.  Keating,  M.D.,  Professor  of  Obstetrics,  in  the  Jefferson  Med.  Coll.,  Phila. 
In  one  large  and  handsome  imperial  octavo  volume  of  050  pages,  strongly  bound  in 
leather,  with  raised  bands;  with  t)4  beautiful  plates,  and  numerous  wood-cuts  in 
the  text,  containing  in  ail  nearly  200  large  and  beautilul  figures.     §7. 


SWAYNE'S  OBSTETRIC  APHORISMS. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COMMENCING  MID- 
WIFERY PRACTICE.  By  Joseph  Griffiths  Swayne,  M.D.  Second  American, 
from  the  fifth  and  revised  London  edition,  with  additions  by  E.  R.  Hutchins,  M.D. 
With  illustrations.     In  one  neat  12mo.  volume.     Cloth,  $1  25. 


HENRY  C.  LEA'S  SON  &  CO.-Philadelphia. 


SMITH  ON  CHILDREN— Now  Beady. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.  By 
J.  Lewis  Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue 
Hospital  Medical  College,  New  York.  Fourth  edition,  revised  and  enlarged.  In 
one  handsome  octavo  volume  of  about  750  pages,  with  illustrations.  Cloth,  $4  50  ; 
leather,  $5  50  ;  very  handsome  half  Russia,  raised  band*,  $6. 

In  the  period  which  has  elapsed  since  the  third  fully  ahreast  of  the  times.    We  cordially  com 

edition  of  the  work,  so  extensive  have  been  the  mend  it  (0  students  and  physicians.    There  iR  no 

advances  that  whole  chapters  required  to  be  re-  better  work  in  the  language  on  diseases  of  chil- 

written.  and  hardly  a  page  could  pass  without  dren  —Cincinnati  Hed  New-,  March,  1879. 
some    material  correction    or    addition^    This        Thjg  excellent  work  ig  g0  wel,  knoWQ  that  an 

labor  has  occnpi^d  the  writer  closely    and    he  extended  nolice  at  thig  time  would  be  8aperflll. 

has  performed  U  conscientiously    so  that   the  oug     The  anth„r  ha„  ,akftn  advantage  of  the 

b->ok  may  be  considered  a  faithful  portraiture  or  demind  for  aDOther  new  eduion  to  revise  in  a 

an   exceptional^   wide  clinical  experience  in  most  carefnl  mannel.  the  entire  book;  and  the 

infantile  disease-,  corrected  by  a  <-areful  stuoy  numeroas  corrections  and  additions  evince  a  de- 

of  the  recent  literature   »f  the  subject  —M-n.  termination  on   hjs  part   t0  k„ep  f,llly  abrea«t 

and  Surg.  Reporter,  April  a,  1879  wi(1)  the  rapjd  progress  tnHt  js  being  made  in  the 

It  is  scarcely  necessary  for  us  to  say  the  work  knowledge  and  treatment  of  children's  diseases, 

before  us  is  a  standard  work  np  >n  di-eises  "f  By  the  adoption  of  a  somewhat  closer  type,  an 

children,  and  that  no  work  has  a  higher  stand-  increae  of  only  thirty  pages  has  been  necessi- 

ingthinit  uponthoseaffections.  In  c  nseqnence  tated  by  the  new  subject-matter  introduced.— 
of  its  thorough  revision,  the  work  has  been  mid?  :  Borton  lle<i.  and  Surg.  Journ.,  May  29,  1879. 
of  more  value  than  ever,  and  may  be  regarded  a*  I 


CONDIE  ON  DISEASES  OF  CHILDREN. 


PRACTICAL  TREATISE  ON  DISEASES  OF  CHILDREN.  By  D.  Francis  Cox- 
die,  M.D.,  Fellow  of  the  College  of  Physicians,  etc.  Sixth  edition,  revised  and 
augmented.  In  one  large  octavo  volume  of  nearly  800  pages.  Cloth,  $5  25  ;  lea- 
ther, $6  25. 


SMITH  ON  THE  WASTING  DISEASES  OF  CHILDREN. 

THE  WASTING  DISEASES  OF  INFANTS  AND  CHILDREN.  By  Eustace  Smith, 
M.D.  Second  American,  from  the  second  and  enlarged  London  edition.  In  one 
very  handsome  octavo  volume  of  266  pages.     Extra  cloth,  $2  50 


DUNCAN  ON  THE  DISEASES  OF  WOMEN— Just  Ready. 

CLINICAL  LECTURES  ON  THE  DISEASES  OF  WOMEN.  Delivered  in  St.  Bar- 
tholomew's Hospital.  By  J.  Matthews  Duxcan,  M.D.,  LL.D.,  F.R.S.  In  one 
very  neat  octavo  volume  of  173  pages.     Cloth,  $1  50. 


WINCKEL  ON  CHILDBED. 


A  COMPLETE  TREATISE  OF  THE  PATHOLOGY  AND  TREATMENT  OF  CHILD- 
BED, for  Students  and  Practitioners.  By  F.  Wisckel,  Professor  and  Director  of 
t^e  Gynaecological  Clinic  in  the  University  of  Rostock.  Translated  with  the  con- 
sent of  the  author,  from  the  second  German  edition,  by  James  Read  Ciiadwick, 
M.D.     In  one  octivo  volume.     Cloth,  $4.      (Lately  Issued.) 


TANNER  ON  PREGNANCY. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.  By  Thomas  H.  Tasver, 
M.D.  First  American,  trom  the  second  and  enlarged  English  edition.  With  four 
colored  plates,  and  a  number  of  illustrations  on  wool.  In  one  handsome  octavo 
volume  of  about  500  pages.     Cloth,  $4  25. 


HENRY  C.  LEA'S  SON  &  CO.— Philadelphia 


HENRY  C.  LEA'S  SON  &  CO.'S 

(LATE  HENRY  C.  LEA) 

ohj^ssizfijieid   o.^t.a.il.o  gmjb 

OF 

MEDICAL  AND  SURGICAL  PUBLICATIONS. 

In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following 
pages,  the  publishers  would  state  that  no  pains  are  spared  to  secure  a  continuance  oi 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  large  number  of  inquiries  received  from  the  profession  for  a  finer  class  of  bind- 
ings than  is  usually  placed  on  medical  book's  has  induced  us  to  put  certain  of  our 
standard  publications  in  half  Russia,  and  that  the  growing  taste  may  be  encouraged, 
the  prices  have  been  fixed  at  so  small  an  advance  over  the  cost  of  sheep,  as  to  place  it 
within  the  means  of  all  to  2)ossess  a  library  that  shall  have  attractions  as  well  for  the 
eye  as  for  the  mind  of  the  reading  practitioner. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  book- 
sellers throughout  the  United  States,  who  can  readily  procure  for  their  customers  any 
works  not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be 
sent  by  mail  post-paid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weight  has 
been  removed,  no  difficulty  will  be  experienced  in  obtaining  through  the  post-office 
any  work  in  this  catalogue.  No  risks,  however,  are  assumed  either  on  the  money  or 
on  the  books,  and  no  publications  but  our  own  are  supplied,  so  that  gentlemen  will  in 
most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Illustrated  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be 
forwarded  by  mail,  post-paid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA'S  SON  &  CO. 
Nos.  TOG  and  708  Sansom  St.,  Philadelphia,  October,  1880. 

INCREASED  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


TWO  MEDICAL  JOURNALS,  containing  nearly  2000  LAEGE  PAGES, 

Free  of  Postage,  for  FIVE  DOLLARS  Per  Annum. 

TERMS  FOR  1880. 

The  American  Journal  of  the  Medical  Sciences,  published   1  Five  Dollars 

quarterly  (1150  pages  per  annum),  with                                             >•  per  annum, 

The  Medical  News  and  Abstract,  monthly  (768  pp.  per  annum),  )  in  advance. 

SEPARATE  SUnSCKIPTIOXS  TO 

The  American  Journal  of  the  Medical  Sciences,  when  not  paid  for  in 

advance,  Five  Dollars. 
The  Medical  News  and  Abstract,  free  of  postage,  in  advance,  Two  Dollars 

and  a  half. 

*^*  Advance  paying  subscribers  can  obtain  at  the  close  of  the  year  cloth  covers, 
<rilt-lettercd,  for  each  volume  of  the  Journal  (two  annually),  and  of  the  News  and 
Abstract  (one  annually),  free  by  mail,  by  remitting  ten  cents  for  each  cover. 

It  will  thus  be  seen  that  for  the  moderate  sum  of  Five  Dollars  in  advance,  the 
subscriber  will  receive,  free  of  postage,  the  equivalent  of  three  or  four  large  octavo 
volumes,  stored  with  the  choicest  matter,  original  and  selected,  that  can  be  furnished 
by  the  medical  literature  of  both  hemispheres.  Thus  taken  together,  the  "Journal," 
and  the  "News  and  Abstract"  combine  the  advantages  of  the  elaborate  prepara- 
tion that  can  be  devoted  to  the  Quarterly  with  the  prompt  conveyance  of  intelligence 
by  the  Monthly;  while  the  whole  being  under  a  single  editorial  supervision,  the  sub- 
scriber is  secured  against  the  duplication  of  matter  inevitable  when  periodicals  from 
different  sources  are  taken  together. 

The  periodicals  thus  offered  at  this  unprecedented  rate  are  universally  known  for 

(For  "  The  Obstetrical  Journal,"  see  p.  34.) 


2     Henky  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Joum.  Med.  So'.). 
their  high  professional  standing. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  M.D., 
for  more  than  half  a  century  has  maintained  its  position  in  the  front  rank  of  the 
medical  literature  of  the  world.  Cordially  supported  by  the  profession  of  America,  it 
circulates  wherever  the  language  is  read,  and  is  universally  regarded  as  a  national  ex- 
ponent of  American  medicine — a  position  to  which  it  is  entitled  by  the  distinguished 
names  from  every  section  of  the  Union  which  are  to  be  found  among  its  collaborators.* 
It  is  issued  quarterly,  in  January,  April,  July,  and  October,  each  number  containing 
about  three  hundred  octavo  pages,  appropriately  illustrated  wherever  necessary.  A 
laro-e  portion  of  this  space  is  devoted  to  Original  Communications,  embracing  papers 
from  the  most  eminent  members  of  the  profession  throughout  the  country. 

Following  this  is  the  Review  Department,  containing  extended  reviews  by  com- 
petent writers  of  prominent  new  works  and  topics  of  the  day,  together  with  numerous 
elaborate  Analytical  and  Bibliographical  Notices,  giving  a  fairly  complete  survey  of 
medical  literature. 

Then  follows  the  Quarterly  Summary  of  Improvements  and  Discoveries 
IN  the  Medical  Sciences,  classified  and  arranged  under  different  heads,  and  furn- 
ishing a  digest  of  medical  progress,  abroad  and  at  home. 

Thus  during  the  year  1879  the  "Journal"  contained  67  Original  Communications, 
mostly  elaborate  in  character,  147  Reviews  and  Bibliographical  Notices,  and  215  articles 
in  the  Quarterly  Summaries,  illustrated  with  70  wood  engravings. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "Journal"  are 

successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 

leading  organ  of  medical  progress: — 

This  is  universally  acknowledged  as  the  leading  i  The  Philadelphia  Medical  and  Physical  Journal 
American  Journal,  and  has  been  conducted  by  Dr.  |  issned  its  first  number  in  1820,  and,  after  a  brilliant 
Hays  alone  until  1869,  when  his  son  was  associated  '  career,  was  succeeded  in  1827  by  the  American 
with  him.  We  quite  agree  with  the  critic,  that  this  .  Journal  of  the  Medical  Sciences,  a  periodical  of 
journal  issecond  to  none  in  the  language,  and  cheer.  ,  world-wide  reputation;  the  ablest  and  one  of  the 

--nal  which  has 
of  American 


fullv  accord  to  it  the  first  place,  for  nowhere  shall   oldest  periodicals  in  the  world — a  journal  which  has 

we  find  more  able  and  more  impartial  criticism,  and  j  an  unsullied  record.— Gross's  History 

nowhere  such  a  repertory  of  able  original  articles. 

Indeed,  now  that  the  "British  and  Foreign  Medico- 

Chirurgical  Review"  has  terminated  its  career,  the 

American  Journal  stands  without  a  rival. — London 

Med.  Times  and  Gazette,  Nov.  24,  1877. 

The  best  medical  journal  on  the  continent. — Bos- 
ton Med.  and  Surg.  Journal,  April,  1879. 
The  present  number  of  the  American  Journal  is 

an  exceedingly  good  one,  and  gives  every  promise 

of    maintaining   the  well-earned  reputation  of  the 

review.     Our  venerable  contemporary  has  our  best 

wishes,  and  we  can  only  express  the  hope  that  it 

may  continue  its  work  with  as  much  vigor  and  ex- 
cellence for  the  next  fifty  years  as  it  has  exhibited 

in  the  past. — London  Lancet,  Nov.  24,  1877. 


Med.  Literature,  1876. 

The  best  medical  journal  ever  published  in  Europe 
or  America. —  Va.  Med.  Monthly,  May,  1879. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. — Boston  Med.  and 
Surg.  Journal,  Oct.  1877. 

This  is  the  medical  journal  of  our  country  to  which 
the  American  physician  abroad  will  point  with  the 
greatest  satisfaction,  as  reflecting  the  state  of  medi- 
cal culture  in  his  country.  For  a  great  many  years 
it  has  been  the  medium  through  which  our  abl<t>t 
writers  have  made  known  their  discoveries  and 
observations.— Address  of  L.  P.  Yandell,  M.V.,  be- 
fore International  Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Pub- 
lishers in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences" 
has  never  been  raised  during  its  long  career.  It  is  still  Five  Dollars  per  annum  ; 
and  when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical 
News  and  Abstract,"  making  in  all  nearly  2000  large  octavo  pages  per  annum,  free 
of  postage. 

II. 

THE  MEDICAL  NEWS  AND  ABSTRACT. 

Thirty-seven  years  ago  the  "Medical  News"  was  commenced  as  a  monthly  to 
convey  to  the  subscribers  of  the  "American  Journal"  the  clinical  instruction  and 

•  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  publishers. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Am.  Journ.  Med.  Sci.).    3 

current  information  which  could  not  be  accommodated  in  the  Quarterly.  It  consisted 
of  sixteen  page*  of  such  matter,  together  with  sixteen  more  known  as  the  Library 
Department  and  devoted  to  the  publishing  of  books.  With  the  increased  progress  of 
science,  however,  this  was  found  insufficient,  and  some  years  since  another  periodical, 
known  as  the  "  Monthly  Abstract,"  was  started,  and  was  furnished  at  a  moderate 
price  to  subscribers  to  the  "American  Journal."  These  two  monthlies  will  here- 
after be  consolidated,  under  the  title  of  "The  Medical  News  and  Abstract," 
and  will  be  furnished  free  of  charge  in  connection  with  the  "American  Journal." 

The  "  News  and  Abstract"  will  consist  of  64  pages  monthly,  in  a  neat  cover.  Jt 
will  contain  a  Clinical  Department  in  which  will  be  continued  the  series  of  Origi- 
nal American  Clinical  Lectures,  by  gentlemen  of  the  highest  reputation 
throughout  the  United  States,  together  with  a  choice  selection  of  foreign  Lectures  and 
Hospital  Notes  and  Gleanings.  Then  will  follow  the  Monthly  Abstract,  systemati- 
cally arranged  and  classified,  and  presenting  five  or  six  hundred  articles  yearly  ;  and 
each  number  will  conclude  with  a  News  Department,  giving  current  professional 
intelligence,  domestic  and  foreign,  the  whole  fully  indexed  at  the  close  of  each  volume, 
rendering  it  of  permanent  value  foy  reference. 

As  stated  above,  the  subscription  price  to  the  "News  and  Abstract"  will  be 
Two  Dollars  and  a  Half  per  annum,  invariably  in  advance,  at  which  rate  it  will  rank 
as  one  of  the  cheapest  medical  periodicals  in  the  country.  But  it  will  also  be  fur- 
nished, free  of  all  charge,  in  commutation  with  the  "American  Journal  of  the 
Medical  Sciences."  to  all  who  remit  Five  Dollars  in  advance,  thus  giving  to  the 
subscriber,  for  that  very  moderate  sum,  a  complete  record  of  medical  progress  through- 
out the  world,  in  the  compass  of  about  two  thousand  large  octavo  pages. 

In  this  effort  to  furnish  so  large  an  amount  of  practical  information  at  a  price  so  un- 
preeedentedly  low,  and  thus  place  it  within  the  reach  of  every  member  of  the  profes- 
sion, the  publishers  confidently  anticipate  the  friendly  aid  of  all  who  feel  an  interest  in 
the  dissemination  of  sound  medical  literature.  They  trust,  especially,  that  the  sub- 
scribers to  the  "American  Medical  Journal,"  will  call  the  attention  of  their 
acquaintances  to  the  advantages  thus  offered,  and  that  they  will  be  sustained  in  the 
endeavor  to  permanently  establish  medical  periodical  literature  on  a  footing  of  cheap- 
ness never  heretofore  attempted. 

PREMIUM  FOR  OBTAINING  NEW  SUBSCRIBERS  TO  THE  "JOURNAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1880,  one  of 
which  at  least  must  be  for  a  new  subscriber,  will  receive  as  a  premium,  free  by  mail, 
a  copy  of  any  one  of  the  following  recent  works  : — 

"Barnes's  Manual  of  Midwifery"  (see  p.  24), 

"Tilbury  Fox's  Epitome   of  Diseases  of  the  Skin,"  new  edition  (see 

p.  18), 
"  Fothergill's  Antagonism  of  Medicines"  (see  p.  16), 
"Holden's  Landmarks,  Medical  and  Surgical"  (see  p.  6), 
"Browne  on  the  Use  of  the  Ophthalmoscope"  (see  p.  29), 
"Flint's  Essays  on  Conservative  Medicine"  (see  p.  15), 
"  Sturges's  Clinical  Medicine"  (see  p.  14), 
"  Swayne's  Obstetric  Aphorisms,"  new  edition  (see  p.  21), 
"Tanner's  Clinical  Manual"  (see  p.  5), 
"West  on  Nervous  Disorders  of  Children"  (see  p.  20). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1880. 

t^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
••Journal"  maybe  made  at  the  risk  of  the  publishers,  by  forwarding  in  registered 
letters.     Address, 

Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Phila.,  Pa. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dictionaries). 


JJUNGLISON  {ROBLEY),  M.D., 

Late  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A.  Dictionary  of  Medical  Science:  Con- 
taining a  toncise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.     A  New  Edition.     Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.     By  Richard  J.  Dcnglison,  M.D.     In  one  very  large  and  hand- 
some royaloctavo  volume  of  over  1100  pages.    Cloth,  $6  50  ;  leather,  raised  bands,  $7  50  ; 
half  Russia,  $8.     {Just  Issued.) 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  nndereach,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.    Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augmentits  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en- 
viable reputation.  During  the  t«n  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenclature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  tothe  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  meohanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 

may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  possesses  forhim  a  filial  as  well 
is  an  individual  interest,  will  be  found  worthy  a  con- 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, Dr.  Richard  J.  Dunglison,  having  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it,  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  state  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition. — Phxla.  Med.  Timet,  Jan.  3, 1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  sine  qua  non.  In  a 
science  so  extensive,  and  with  such  collaterals  as  medi 
cine,  it  is  as  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physkians,  the  dictionary  must  be  condensed  while 
comprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  additions  been 
so  great.  More  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chief  terms  have  been  =et  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.    We 


tinuance  of  the  position  so  long  accorded  to   it 
standard  authority." — Cincinnati  Clinic,  Jan.  10, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — Loudon  Medical  (lazrtte 

As  a  standard  work  of  reference,  as  one  of  the  best, 
if  not  the  very  best,  medical  dictionary  in  the  Eng- 
lish language,  Dunglison's  work  has  been  well  known 
for  about  forty  years,  and  needs  no  words  of  praise 
on  our  part  to  recommend  it  to  the  members  of  the 
medical,  and,  likewise,  of  the  pharmaceutical  pro- 
fession. The  latter  especially  are  in  need  of  such  a 
work,  which  gives  ready  and  reliable  information 
on  thousands  of  subjects  and  terms  which  they  are 
liable  to  encounter  in  pursuing  their  daily  avoca- 
tions, but  with  which  they  cannot  be  expected  to  be 
familiar.  The  work  before  us  fully  supplies  this 
want. — Am.  Journ.  of  Pharm.,  Feb.  1S74. 

A  valuable  dictionary  of  the  terms  employed  in 
medicine  and  the  allied  sciences,  and  of  the  rela- 
tions of  the  subjects  treated  under  each  head.  It  re- 
flects great  credit  on  its  able  American  author,  and 
well  deserves  the  authority  and  popularity  it  has 
obtained.— British  Med.  Journ.,Oct.  31,  1S74. 

Few  works  of  this  class  exhibit  a  grander  monu- 
ment of  patient  research  and  of  scientific  lore.  The 
extent  of  the  sale  of  this  lexicon  is  sufficient  to  tes- 
tify to  its  usefulness,  and  to  the  great  service  con- 
ferred by  Dr.  Robley  Dunglison  on  the  profession, 
and  indeed  on  others,  by  its  issue. — London  Lancet , 
May  18.  lt-7a. 


LJOBLYN  {RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  Isaac  Hays, 
M.  D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
I2mo.  volume  of  over  500  double-columned  pages;  cloth,  $1  50;  leather,  $2  00 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table.—  Southern 
Med.  and  Surg  Journal. 

JDODWELL  (G.  F.),  F.R.A.S.,  frc. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 
istry, Dynamics,  Electricity,  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations:  cloth,  $5. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Manuals).  5 

A  CENTURY  OF  AMERICAN  MEDICINE,  1776-1876.  By  Doctors  K.  H. 
-^*-  Clarke,  II.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.  Inone  very  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  25.     (Lately  Issued.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medioal  Sciences  during  the 
year  1876.  As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
come it  in  a  form  adapted  for  preservation  and  reference. 


jyEILL  {JOHN),  M.D.,  and     CtMITH  {FRANCIS  O.),  M.D., 

"^  Prof  .of  the  Institutes  of  Medicine  intheUniv.of  Penna 

AN    ANALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo. 
volume,  of  about  one  thousand  pages,  with  374  wood-outs,  cloth,  $4  ;  strongly  bound  n 
leather,  with  raised  bands,  $4  75. 


H 


ARTSHORNE  {HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF   THE   MEDICAL   SCIENCES;   containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia   Medica,   Practical  Medicine, 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  on 
wood.     Cloth,  $4  25  ;  leather,  $5  00.     (Lately  Issued.) 
We  can  say  with  the  strictest  truth  that  it  is  the  ]  worthy.     If  students  must  have  a  conspectus,  they 
best  work  of  the  kind  with  which  wt  artacquainted.  i  will  be  wise  to  procure  that  of  Dr.  Hartshorne.— 
It  embodies  in  a  condensed  form  all  recent  coutribu-  I  Detroit  Rev.  of  Sled  and  Pharm    Aug   1874 
tions  to  practical  medicine,  and  is  therefore  useful  |      The  work  M  however,  has  many  redeem 

to  every  busy  practitioner  throughout  our  country,     . 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.    The  book  is  faithfully  and  ably 
executed.— Charleston  Med.  Journ.,  April,  1875. 

The  work  is  intended  as  an  aid  to  the  medical 
student,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  full  compi- 
lation of  facts,  the  perspicuity  and  terseness  of  lan- 
guage, and  the  clear  and  Instructive  illustrations 
in  some  parts  of  the  work — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 

The  volume  will  be  found  useful,  not  only  to  stu- 
dents, but  to  many  otherswhomay  desire  torefresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — N.  T.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand.— Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 
This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concise 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it, so  far  as  it  goes,  entirely  trust- 


ing features  not  possessed  by  other*,  and  is  the  best 
we  have  seen.  Dr.  Hartshorne  exhibits  much  skill  in 
condensation.  It  is  well  adapted  to  the  physician  in 
active  practice,  who  can  give  but  limited  time  to  the 
familiarizing  of  himself  with  the  important  changes 
which  have  been  made  since  he  attended  lectures. 
The  manual  of  physiology  has  also  been  Improved 
and  gives  the  most  comprehensive  view  of  the  latest 
advances  in  the  science  possible  in  the  space  devoted 
to  the  subject.  The  mechanical  execution  of  the 
book  leaves  nothing  to  be  wished  for. — Peninsular 
Journal  of  Medicine,  Sept.  1874. 

After  carefully  looking  through  this  conspectus, 
we  are  constrained  to  say  that  it  is  the  most  com- 
plete work,  especially  in  its  illustrations,  of  its  kind 
that  we  have  seen. — Cincinnati  Lancet,  Sept.  1874. 

The  favor  with  which  the  first  edition  of  this 
Compendium  was  received,  was  an  evidence  of  its 
various  excellences.  The  present  edition  bears  evi- 
dence of  a  careful  and  thorough  revision.  Dr.  Harts- 
horne possesses  a  happy  faculty  of  seizing  upon  the 
salient  points  of  each  subject,  and  of  presenting  them 
in  a  concise  and  yet  perspicuous  manner. — Leaven- 
worth Med.  Herald,  Oct.  1S74 


J  UDLOW  {J.L.),  M.D. 

A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
ble  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


T 


'ANNER  {THOMAS  HAWKES),  M.D.,fyc. 
A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.    Third  American  from  the  Second  London  Edition.    Revised  and  Enlarged  by 
Tilbury  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospital, 
<fcc.   In  one  neat  volume  small  1 2mo.,  of  about  375  pages,  cloth,  $150. 
*%*  On  page  3,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "  American  Journal  of  the  Medical  Sciences." 


6  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Anatomy). 

QRAT  {HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  Oeorge's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.    The  Drawings  by 

H.  V.  Carter,  M.D. , and  Dr.  Westmacott.    The  Dissecbionsjointly  by  the  Author  and 
Dr.  Carthr.     With  an   Introduction    on    General   Anatomy  and  Development  by  T. 
Holmes,  M.A.,  Surgeon  to  St.  George's  Hospital.     A  new  American,  from  the  eighth 
enlargec  and  improved  London  edition.     To  which  is  added  "  Landmarks,  Medical  and 
Surgical,"  by  Luther  Holder:,  F.R.C.S.,  author  of"  Human  Osteology,"  "  A  Manual 
of  Dissections,"  etc.     In  one  magnificent  imperial  octavo  volume  of  983  pages,  with 
522  large  and  elaborate  engravings  on  wood.     Cloth,  $6;  leather,  raised  bands,  $7; 
half  Russia,  $7  60.     (Just  Ready.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended raDge  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  acomplete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  typeand 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  siie,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

The  recent  work  of  Mr    Holden,  which  was  no- 1  to   consult   his  books  on   doatom>.    The   work   is 
ticed  by  as  on  p.  53  of  this  volume,  has  been  added  i  simply  indispensable,  especially  this  present  Amer- 
a>  an  appendix,  so  that,  altogether,  this  is  the  raoft    ican  edition.— Fa.  Med.  Monthly,  Sept.  1878. 
practical  and  complete  anatomical  treatise  available 
to  American  students  and  physicians.    The  former 
finds  in  it  the  necessary  guide  in  making  dissec- 
tions; a  very  comprehensive  chapter  on   minute 
anatomy;  and  abont  all  that  can  be  tanght  him  on 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  edition  of  Mr    Holden, 
will  'find  all  that  will  be  essential  to  him  in  his 
practice.— Sew  Remedies,  Aug  1878. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  as  a  j  It  is  difficult  to  speak  in  moderate  terms  of  this 
text-book  or  a  general  reference  book  on  anatomy  I  new  edition  of  "Gray."  It  seems  to  be  as  nearly 
to  be.  The  American  publisher  deserves  the  thanks  '  perfect  as  it  is  possible  to  make  a  book  devoted  to 
of  the  profession  for  appending  the  recent  work  of  j  any  branch  of  medical  science.  The  labors  of  the 
Mr.  Holden,  "Landmarks,  Medical  and  Surgical,"  eminent  men  who  have  successively  revised  the 
which  has  already  been  commended  as  a  separate  eight  editions  through  which  it  has  passed,  would 
book.  The  latter  work— trexting  of  topographical  seem  to  leave  nothing  for  future  editors  to  do.  The 
anatomy— has  become  an  essential  to  the  library  of  j  addition  of  Holden's  "  Landmarks"  will  make  it  as 
every  intelligent  practitioner.  We  know  of  do  j  indispensable  to  the  practitioner  of  medicine  and 
book  that  can  take  its  place,  written  as  it  is  by  a  |  surgery  as  it  has  been  heretofore  to  the  student.  As 
most  distinguished  anatomist.  It  would  be  simply  J  regards  completeness,  ease  of  reference,  utility, 
a  waste  of  words  to  say  anything  further  in  praise  |  beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
of  Oray's  Anatomy,  the  text-book  in  almost  every  j  dent  should  enter  a  medical  school  without  it ;  no 
medical  college  in  this  country,  and  the  daily  refer  ;  physician  can  afford  to  have  it  absent  from  his 
ence  book  of  every  practitioner  who  has  occasion  |  library  —St.  Louis  Glin.  Record,  Sept.  1878. 

Also  for  sale  separate — 
-[TOLD EN  [LUTHER),  F.R.C.S., 

-"-  Surgeon  to  St.  Bartholomew's  and  the  Foundlir.  g  Hospitals, 

LANDMARKS,  MEDICAL  AND  SURGICAL.   From  the  2d  London 

Ed.   In  one  handsome  volume,  royal  12mo;,  of  1 23  pages  :  cloth,  88  cents.    (Now  Ready.) 

TJEATH  (CHRISTOPHER),  F.R.C.S., 

-Ll  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:   A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keek, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo. volume  of  578  pages,  with  247  illustrations.  Cloth,  $3  50; 
leather,  $4  00. 


The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  American  students, 
who  find  in  it  a  comprehensive  chapter  on  minute 
auatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  vie<r,  in  the  valu- 
able section  by  Mr  Holden.  is  all  that  will  be  essen- 
tial to  them  in  practice.— Ohio  Medical  Recorder, 
Aug  1878. 


Henry  C.  Lea's  Son  <fc  Co.'s  Publications — (Anatomy). 


A  LLEN  (HARRISON),  M.D. 

•£*-  Prof  tenor  of  Physiology  in  th*  Univ.  of  Pa 

A  SYSTEM  OF  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Studentsof  Medicine.   With  «n 
Introductory  Chapter  on  Histology   By  E.  0.  Shakespeare,  M  D  ,  Ophthnlmologistto  the 
Phila.  Hosp.    In  one  large  and  handsome  quarto  volume  with  several  hundred  original 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  text.     (In  Press.) 
Ih  this  elaborate  work,  which  has  been  inactive  preparation  for  several  years,  the  author  has 
sought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clear  and  condensed  form,  but  also 
the  pract  ical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  thesignificance  of  allvaria- 
tions  from  normal  conditions      The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self  evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissections,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "  Gray, "  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

PLUS  {GEORGE  V1NER)~ 

■U  Emeritus  Prof essor  of  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  OF  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  George  Viner  Ellis,  Emeritus  Professor 
of   Anatomy  in    University  College,   London.     From  the  Eighth  and  Revised  London 
Edition.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
Cloth,  $4.25  ;  leather,  $5.25.      (Just  Ready  ) 
This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  as  is  attested  by  the  numerous  editions  through 
which  it  has  passed.     In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

Ellis's  Demonstrations  is  the  favorite  text-book  i  its  leadership  over  the  English  manuals  upon  dis- 
of  the   English   student   of  anatomy.     In  passing  I  secting. — Phila.  Med.  Times,  May  24,  1879. 
through  eight  editions  it  has  been  so  revised  and  | 

adapted  to  the  needs  of  the  student  hat  it  would  As  a  dissector,  or  a  work  to  have  in  hand  and 
seem  that  it  had  almost  reached  perfection  in  this  '  studied  while  one  is  engaged  in  dissecting,  we  re 
special  line.  The  descriptions  are  clear,  and  the  !  8ard  u  as  the  veT  best  work  extant,  which  is  cer- 
methods  of  pursuing  anatomical  investigations  are  !  tainly  saying  a  very  great  deal.     As  a  text-book  to 


given  with  such  detail  that  the  book  is  honestly 
entitled  to  Us  name.— St.  Louis  Clinical  Record. 
Jane,  1879. 

The  success  of  this  old  manual  seems  to  be  as  well 
deserved  in  the  present  as  in  the  past  volumes. 
The  book  seems  destined  to  maintain  yet  for  years  '  Va.  Med.  Monthly,  June,  1S79 


be  studied  in  the  dissecting-room,  it  is  superior  to 
any  of  the  works  upon  anatomy.—  Cincinnati  Med. 
News,  May  24,  1879. 

We   most  unreservedly  recommend   it  to  every 
practitioner  of  medicine  who  can  possibly  get  it. — 


w 


8 


S 


ILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.Gobrecht,  M.D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  ootavo  volume,  of  over  600  large  pages  ;  cloth,  $4  ;  leather,  $5. 

MITH  [HENRY H.),  M.D.,         and  JJORNER  (  WILLIAM  E.),  M.D., 

Prof  .of  Surgery  in  the  Univ.  of  Penna.,  Ac.  Late  Prof,  of  Anatomy  in  the  Univ.  ofPenna. 

AN   ANATOMICAL   ATLAS  ;   illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  ootavo,  cloth,  with  about  six  hundred  and 
fifty  beautiful  figures.     $4  50. 

CHAFER  {ED  WARD  ALBERT),  M.D., 

Assistant  Profet-sor  of  Physiology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.  In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     (Just  Issued.) 


HORNER'S  SPECIAL  ANATOMY  AND    HISTOL- >      for  their  Pass  Examination.   With  engravings  on 

OGY.     Eighth  edition,  extensively  revised  and  i      wood.     In   one   handsome   royal  12mo.  volume. 

modified.     In  2  vols.   8vo.,  of  over  1000   pages,  j      Cioth,  $2  25. 

with  320  woodcuts  :  cloth.  $6  00  CLELAND'S  DIRECTORY  FOR  THE  DISSECTION 

SHARPEY    AND    QUAIN'S    HUMAN    ANATOMY.,      OF  THE  HUMAN  BODY.     In  one  small  volume, 

Revised,  by  Joseph  Lkidy,  M.D.,  Prof  of  Anat.  '      royal  12nio.  of  1S2  pages:  oloth  #1  25. 

in  Uuiv.  of  Penn.     In  two  octavo  vols,  of  about     HARTSBORNE'S  HANDBOOK  OF  ANATOMY  AND 

1300  pages,  with  511  illustrations  Cloth,  $6  00.  PHYSIOLOGY.  Second  edition,  revised.  In  one 
BELLAMYS    STUDENT'S    GUIDE   TO    SURGICAL        royal   12mo.    vol.,   with    220   woodcuts      cloth 

ANATOMY:  A  Text-book  for  Students  preparing  ,      $1  75. 


8 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology). 


flARPENTER  (  WILLIAM  B.),  M.D.,  F.R.S.,  F.O.S.,  F.L.S., 

^  Registrar  to  University  of  London,  etc . 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HenryPower, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  Anew 
American  from  the  Eigbtb  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  Francis  G. Smith,  M.D.,  Professor  of  the  Institutes  of  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  373  engravings  on  wood,-  cloth,  $5  50  ;  leather,  $6  50  ;  half  Russia, 
$7.  (Just  Issued.) 
We  have  been  agreeably  surprised  to  find  the  vol- )  new  a  year  or  two  apo.  looks  now  as  if  it  had  been  a 


nine  so  complete  in  regard  to  the  structure  and  func 
tlons  of  the  nervous  system  In  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
whieh  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  wiih  their  additions  to  the  only 
work  on  physiologyin  ourlanguage  that, in  thefull- 
est  sense  of  the  word,  is  the  production  of  a  philoso- 


received  and  established  fact  for  years.  In  this  ency- 
clopaedic way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  vaiue  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 
subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gazette,  Feb.  17,1877. 

The  merits  of  "Carpenter'sPhysiology"  are  so  widely 
known  and  appreciated  chat  we  need  only  allude  briefly 
to  the  fact  that  in  the  latest  edition  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio- 
logical investigation.  Care  has  been  taken  to  preserve 


pher  as  well  as  a  physiologist,  brought  it  up  as  fully    t£e  pracucai  character  of  the  original  work.    In  fact 

as  could  be  expected,  If  not  desired,  to  the  standard  ' 

of  our  knowledge  of  its  subject  at  the  present  day. 

It  will  deservedly  maintain  the  place  it  has  always 

had  in  the  favor  of  the  medical  profession. — Journ. 

of  Nervous  and  Mental  Disease,  April,  1877. 

Such  enormous  advances  haverecentlybeen  made  in 
our  physiological  knowledge,  that  what  was  perfectly 


the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition.— N.  T.  Med.  Journal,  Jan.  1877. 


JjTOSTER  {MICHAEL),  M.D.,  F.R.S., 

J-  Prof,  of  Physiology  in  Cambridge  Univ.,  England. 

TEXT-BOOK  OF  PHYSIOLOGY.     A  new  American,  from  the  last 

English  edition.  Edited  with  notes  and  additions  by  Edward  T.  Reichert,  M.D., 
Demonstrator  of  Experimental  Therapeutics  in  Univ.  of  Penna  In  one  handsome  royal 
12mo.  volume  of  1030  pages,  with  259  illustrations.  Cloth,  $1  50.  Leather,  $2  00 
( Just  Ready.) 

American  Editor's  Preface. 
The  high  reputation  acquired  on  both  sides  of  the  Atlantic  by  Dr.  Foster's  "Text-Book  on 
Physiology,"  as  a  lucid  exposition  of  functional  physiology,  in  its  mosC modern  aspect,  has  seemed 
to  call  for  an  edition  more  thoroughly  adapted  to  the  wants  of  the  American  student.  The  plan 
of  the  author  has  presupposed  an  acquaintance  with  the  details  of  physiological  anatomy  such  as 
the  student  is  accustomed  to  look  to  in  his  treatises  on  physiology.  The  absence  of  these 
details  has  rendered  many  parts  of  the  work  vague,  if  not  altogether  incomprehensible,  and  has 
therefore  proved  a  serious  drawback  to  the  usefulness  of  the  book  as  an  accompaniment  to  lec- 
tures on  physiology,  as  it  is  usually  taught  in  our  schools,  and  this  deficiency  the  editor  has 
endeavored  to  supply,  by  brief  notes  and  the  introduction  of  a  large  number  of  illustrations. 

The  almost  limitless  amount  of  material  accumulated  by  modern  research  has  rendered  diffi- 
cult the  task  of  selection  and  compression,  without  exceeding  the  reasonable  limits  of  a  conve- 
nient text-book.  In  his  selection  the  editor  has  been  guided  by  his  experience  in  the  wants  of 
students,  and  has  endeavored  merely  to  present,  in  the  most  concise  form,  such  facts  as  would  seem 
to  be  indispensable  to  a  correct  appreciation  of  the  structure  and  function  of  the  important 
organs.  In  accomplishing  this,  his  additions  have  considerably  exceeded  his  expectations, 
amounting  to  about  140  pages,  including  the  illustrations  whieh'have  been  increased  in  number 
from  72  to  259.  If  he  shall  thus  have  succeeded  in  rendering  this  admirable  work  better  fitted 
for  the  wants  of  the  American  student,  he  will  feel  abundantly  rewarded. 

Nothing  has  been  omitted  from  the  English  edition,  and  all  additions  have  been  distin- 
guished by  insertions  in  brackets  [ — ]. 


The  great  popularity  of  "Foster's  Textbook  of 
Physiology,"  both  in  England  and  in  this  country, 
renders  it  unnecessary  to  say  anything  farther  re- 
garding its  merit.  We  shall,  therefore,  simply 
point  oat  that,  in  the  American  edition,  numerous 
important  additions  have  been  made  to  the  text  of 
the  third  English  edition  whereby  the  usefulness  of 
the  work  as  a  text-book  for  students  has  been  greatly 
increased.— Phila.  Med.  and  Surg.  Reporter,  April 
24,  1880. 

The  additions  of  the  American  editor  are  so  copi 


editor.  So  ably  and  so  thoroughly  has  the  editor 
performed  his  task,  that  we  have  no  hesitancy  in 
saying  that,  in  our  opinion,  the  American  edition 
is  far  superior  to  its  English  contemporary.  In  its 
present  form  we  confidently  recommend  this  text- 
book to  the  student  a*  a  clear,  concise,  and  thor- 
oughly reliable  exposition  of  modern  physiology. 
— Am.  Journ.  of  Med  Sciences,  July,  1880. 

The  matter  of  the  last  English  edition  has  been 
transferred  bodily  to  this,  and  there  have  been 
added  very  many  illustrations  and  copious  notes 


ous  and  important  as  to  largely  increase  the  book's  '  on  histology  and  embryology  by  the  American  edit 
sphere  of  usefulness.  In  notices  of  former  editions,  j  or.  The  English  editions  have  been  defective,  so 
we  alluded  to  the  absence  of  any  reference  to  the  far  as  American  students  are  concerned,  in  their 
physiological  anatomy  of  the  different  organs,  and  dearth  of  illustrations  and  the  absence  of  all  discos- 
the  dearth  of  illustrations  as  serious  drawbacks  to  j  sion  of  physiological  anatomy.  These  being  sup 
the  value  and  general  usefulnees  of  Dr.  Foster's  plied  in  this  edition,  the  work  is  now  undoubtedly 
work.  These  faults  of  omission  have  been  intelli-  I  the  best  on  physiology  in  the  English  language.— 
gently  and  quite  fully  supplied  by  the  American  |  Ohio  Med.  Recorder,  June,  1880. 

THE    SAME.     English   Student's   Edition,  without  notes  or   additions. 

Latest  issue.    In  one  small  12mo.  volume  of  804  pages  with  72  illustrations.    Cloth,  75  cts. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Physiology,  Chemistry).  9 


n ALTON  (J.  C),  M.D., 

■U  Professor  of  Physiology  In  the  College  of  Physicians  and  Surgeons,  New  York ,  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.   Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  re  vised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.    In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.  Cloth,  $5  60;  leather,  $6  50;  half  Russia,  $7.  {Lately  Issued.) 
During  the  past  few  years  several  new  works  on  pby-1  notation  and  nomenclature  have  also  been  introduced 
siology,  and  new  editions  of  old  works,  have  appeared,    into  the  present  edition.    Notwithstanding  the  multi- 
competing  for  the  favor  of  the  medical  student,  but    Dllcity  of  text-books  on  physiology, this  will  lose  none 
none  will  rival  this  new  edition  of  Dttlton.   As  now  en-    of  itg  old  time  popularity.    The  mechanical  execution 
Urged,  It  will  be  found  also  to  be, in  general,  a  satisfac-    0f  the  work  is  all  that  could  be  desired. — Peninsular 
tory  work  of  reference  for  the  practitioner. — Chicago    journal  of  Medicine,  Dec.  187 '5. 

Med.  Journ.  and  Examiner,  3 an.  1876.  This  popular  text-book  on  physiology  comes  to  us  in 

Prof.  Dal  ton  has  discussed  conflicting  theories  and  I  its  sixth  edition  with  the  addition  of  about  fifty  peT  cent, 
conclusions  regarding  physiological  questions  with  a  |  0f  new  matter,  chiefly  in  the  departments  of  patbo- 
fitimess,  a  fulness,  and  a  conciseness  which  lend  fresh-  logical  chemistry  and  the  nervous  system,  where  the 
nessand  vigor  to  the  entire  book.   But. his  discussions    principal  advances  have  been  realized.    With  so  tho- 


have  been  so  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  mindsof  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errorswhile  making  them  astudy. — TheMedical 
Record,  Feb.  19, 1876. 

The  revision  of  thisgreatworkhas.broughtitforward 
with  the  physiological  advances  of  theday,  and  renders 
it,  as  it  ha*  ever  been,  the  finest  work  for  students  ex- 
tant.— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1876. 

For  clearness  and  perspicuity,  Dalton's  Physiology 
commended  itself  to  the  student  years  ago,  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiology  has.  however,  made  many  ad- 
vances since  then— anil  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreast  oi the  times.  The  new  chemical 


rough  revision  and  additions,  that  keep  the  work  well 
up  to  the  times,  its  continued  popularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. — St.  Louis  Med. and  Surg.  Journ.,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirable  text  book,  than  which  there  are  none  of  equal 
brevity  more  valuable.  It  iscordially  recommended  by 
the  Professor  of  Physiology  in  the  University  of  Louisi- 
ana, as  by  all  competent  teachers  in  the  United  States, 
and  wherever  the  English  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  316 
admirably  executed  illustrations. has  been  carefully 
revised  and  very  much  enlarged,  although  its  bulk  does 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1876. 


flREENE  {WILLIAM  H.),  M.D., 

*-"  Demonstrator  of  Chemistry  in  Med.  Dept  ,  Univ.  of  Penna. 

A  MANUAL  OF  MEDICAL  CHEMISTRY.    For  the  Use  of  Students. 

Based  upon  Bowman's  Medical   Chemistry.     In   one  royal  12mo.  volume  of  312  pages. 

With  illustrations.  Cloth,  $1  75.  (Just  Issued.) 
It  is  well  written,  and  gives  the  latest  views  on  The  little  work  before  ns  is  one  which  we  think 
vital  chemistry,  a  subject  with  which  most  phy-i-  will  be  studied  wtth  pleasure  and  profit.  The  de- 
ciaus  are  not  sufficiently  familiar.  To  those  who  so  lotions,  though  brief,  are  clear,  and  in  most  cases 
may  wish  to  improve  their  knowledge  in  that  direc  sufficient  for  the  purpose  This  book  will,  in  nearly 
tion,  we  can  heartily  recommend  this  work  as  being  all  cases,  meet  general  approval.—  Am.  Journ.  of 
worthy  ofa  careful  perusal.  —Phila.  Med.and  Swg.  Pharmacy,  April,  1S80. 
Reporter,  April  24,  1880. 

HLASSEN  {ALEXANDER), 

^  Professor  in  the  Royal  Polytechnic  School,  Aix  la-Chapelle. 

ELEMENTARY   QUANTITATIVE    ANALYSIS.     Translated  with 

note*  and  additions  by  En»AK  F.  Smith,  Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.  In  one  handsome  royal  12mo.  volume,  of  324 
pages,  with  illustrations;  cloth,  $2  00.     (Just  Ready.) 


SCALLOWAY  (ROBERT),  F.C.S.,  /-     '      • 

*-*  Prof  of  Applied  Chemistry  in  the.  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12tuo.  volume,  with  illustrations  ;  cloth,  $2  75.  (Lately 
Is  sit  ed. ) ' 

EMSEN{IRA),  M.D.,  Ph.D., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore. 

PRINCIPLES  OF  THEORETICAL  CHKMISTLIY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.   In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 


R 


BOWMAN'S  INTRODUCTION  TO  PRACTICAL 
CHEMISTRY,  INCLUDING  ANALYSIS.  Sixth 
American,  from  the  sixth  and  revised  London  edi- 
tion. With  numerous  illustrations.  In  one  neat 
vol.,  royal  12mo.,  cloth,  $2  25. 

WOHLER  AND  FITTIG'S  OUTLINES  OF  ORGANIC 
CHEMISTRY.  Translated  with  additions  from  the 
Eighth  German  Edition.  By  Ira  Remse.v.  M  D  , 
Ph.D.,  Prof,  of  Chemistry  and  Physics  in  Williams 


College,  Mass.     In  one  volume,  royal  12mo.  of  550 
pp.,  cloth,  S3. 
LEHMANN'S  MANUAL  OF  CHEMICAL  PHYSIOL- 
OGY.   Translated  from  the  German,  with  Notes 
and  Additions,  by  J.  Cheston  Morkis,  M.D.   With 
illustrations  on  wood.     In  one  octavo  volume  of 
336  pages.     Cloth,  $2  25. 
LEHMANN'S  PHYSIOLOGICAL  CHEMISTRY.  Com- 
plete in  two  large  octavo  volumes  of  1200  pages, 
I      with  200  illustrations;  cloth,  $6. 


10  Henry  C.  Lea's  Son  &  Co.'s  Publications — (Chemistry). 


JPOWNES  (GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.   Revised  and  corrected  by  Uknry  Watts,  B.A.,  F  R.S.,  uuthor  of  A  Diction- 
ary of  Chemistry,"  etc.    'With  a  colored  plate,  and  one  hundred  and  seventy-seven  illus- 
tration*.   A  new  American,  from  th<  twelfth  and  enlarged  London  edition.     Edited  by 
Robert  Bridges,  M.D.       In   one  large  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.     (Just  Issued.) 
Two  careful  revisions  by  Mr.  Watts,  since  the  appearance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.   In 
reprinting  it,  by  the  use  of  a  smaM  and  exceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.  The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 

This  work,  inorganic  and  organic,  is  complete  in  what  formidable  magnitude  with  its  more  than  a 
one  convenient  volume.  In  its  earliest  editions  it  I  thousand  pages,  but  with  less  than  this  no  fair  repre- 
was  fully  up  to  the  latest  advancements  and  theo-  |  sentation  of  chemistry  as  it  now  is  can  be  given.  The 
ries  of  that  time.  In  its  present  form,  it  presents,  |  type  is  small  but  very  clear,  and  the  sections  are  very 
in  a  remarkably  convenient  and  satisfactory  man-  i  lucidly  arranged  to  facilitate  study  and  reference. — 


n>r,  the  principles  and  leading  facts  of  thecbemi-trv 
of  to-day.  Concerning  the  manner  in  which  tbe 
various  subjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praise  of  the.  book.  A  re- 
view of  such  a  work  at  Foumes's  Chemistry  within 
the  limits  of  a  bcok-notice  for  a  medical  weekly  is 


simply  out  ofthe  question.— Cincinnati  Lancet  and    ganic  chemistry.     The  book   has  always  been  a  fa 


Clinic,  D^c.  14, 1878 

When  we  state  that,  in  our  opinion,  the  present 
edition  snstaius  in  every  respect  tie  high  reputation 
which  its  predecessors  Lave  acquired  and  eujoyed, 
we  express  therewith  onr  full  belief  in  lis  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Phfirm.,  Aug.  1878. 

Tbe  conscientious  care  which  has  been  bestowed 
upon  it  by  tbe  American  and  English  editors  renders 
it  still,  perhaps,  tbe  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
ef  his  student  days.    It  has,  indeed,  reached  a  some- 


MeA   and  Surg.  Reporter,  Aug  3,1878. 

Tbe  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  suffice  it  to  say  that 
the  revision  by  tbe  Kngli-h  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  bas  added  some 
fresh  and  valuable  matter,  especially  in  tbe  inor- 


vorite  in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prcstige. — Boston  Jour, 
of  Chemistry,  Ang.  1S78. 

It  will  be  entirely  unnee«ssary  for  us  to  make  any 
remarks  relating  to  tbe  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
totirneleavelittlechanee  for  any  wideswakerival  to 
step  before  it. — Canadian  Pharm.  Jour.,  Ang.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language.— Md.  Med.  Jour.,  Ang.  1878. 


A  TTFIELD  {JOHN),  Ph.D., 

«*■*■  Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  *«. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

including  the  Chemistry  of  the  U.  8.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eighth  edition  revised 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.     (Just  Ready.) 

We  have  repeatedly  expressed  our  favorable  of  chemistry  in  all  the  medical  colleges  in  tbe 
opinion  of  this  work,  and  on  the  appearance  of  a  ,  United  States.  The  present  edition  contains  such 
new  edition  of  it,  little  remains  for  us  to  say,  ex-  alterations  and  additions  as  seemed  necessary  for 
cept  that  we  expect  this  eighth  edition  to  be  as  I  the  demonstration  of  the  latest  developments  of 
indispensable  to  us  as  the  seventh  and  previous  chemical  principles,  and  the  latest  applications  of 
editions  have  been.  While  the  general  plan  and  chemistry  to  pharmacy.  It  is  scarcely  necessary 
arrangement  have  been  adhered  to,  new  matter,  for  us  to  say  that  it  exhibits  chemistry  in  its  pre- 
has  been  added  covering  the  observation?  made  ;  sent  advanced  state. — Cincinnati  Medical  dittos, 
since  tbe  former  edition      The  present  differs  from  '  April,  1879. 

the  preceding  one  chiefly  In  these  alterations  and  ;  Tbe  popniarity  which  this  work  bas  enjoyed  is 
in  about  ten  pages  of  useful  tables  added  In  the  >  owi  f0  the  origicai  and  clear  disposition  ofthe 
appendix  -Am  Jour,  of  Pharmacy,  May,  18-9.        ;  facu  of  the  8CleQce  tbe  accnracy  of  the  details,  and 

A  standard  work  like  Attfield's  Chemistry  need  ;  the  omission  of  much  which  freights  many  treatises 
only  be  mentioned  by  its  name,  without  further  '  heavily  without  brlugiogeorrespondinglnstruetloa 
comments  The  present  edition  contains  snch  al  I  to  the  reader.  Dr.  Attfield  writes  for  students,  and 
terations  and  additions  as  seemed  necessary  for  j  primarily  for  medical  students;  he  always  bas  aa 
the  demonstration  of  the  latest  developments  of  eye  to  the  pharmacopoeia  and  its  officinal  prepara- 
chfmtcal  principles,  and  tbe  latest  applications  of  tious;  and  he  is  continually  putting  the  matter  in 
chemistry  to  pharmacy.  The  author  has  bestowed  the  text  so  that  it  responds  to  tbe  questions  with 
ardnons  labor  on  the  revision,  and  the  ex'ent  of  which  each  section  is  provided.  Tbns  the  student 
the  Information  thus  introduced  may  be  estimated  learns  easily,  and  can  always  refresh  and  test  bis 
from  the  fact  that  the  Index  contains  three  hun-  knowledge. — Med  and  Surg'.  Reporter,  Apri.  19,  '79. 
dred  new  references  relating  to  additional  mater-  We  noMwd  oniy  abollt  two  Tear8  and  a  na!f  ago 
U\.~ Druggists'  Circular  and  Chemical  Qtuette.\  tb,  publication  of  the  preceding  edition,  and  re- 
May,  1879.  I  marked  upon  tbe  exceptionally  valuable  character 

This  very  popular  and  moritorlons  work  has  of  tbe  work.  The  work  now  i'l eludes  the  whole  of 
now  reached  Us  eighth  edition,  which  fact  speaks  the  chemistry  of  the  pharmacopoeia  of  tbe  Doited 
In  the  highest  terms  in  commendation  of  its  excel-  ;  States  Great  Britain,  and  India. — New  RemedUs, 
lesce.     It  has  now  become  the  principal  text-book  ■  May,  1879. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Chemistry).         11 


T>LOXAM  (C.L.), 

•*-*  Professor  of  Chemistry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lon- 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00  ;  leather,  $5  00.     {Lately  Issued.) 


We  have  In  this  work  a  complete  and  most  excel- 
lent text-book  for  the  use  of  schools,  and  can  heart- 
ily recommend  it  as  such. — Boston  Med. and  Surg. 
Journ.,  May  28, 1874. 

The  above  is  the  title  of  a  work  which  we  can  most 
conscientiously  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  thesainetime  that  it  presentsa  fullaceouut 
of thatscience  as  it  now  stands.  We  have  spoken 
of  the  work  as  admirably  adapted  to  the  wants  of 
students  ;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  what  is 
tuecheraistry  ofthe  preaentday.—  American  Prac 
titioner,  Nov.  1873. 


It  would  be  difficult  for  a  practical  chemist  and 
teacher  to  flint  any  material  fault  with  this  most  ad- 
mirable treatise.  The  author  has  given  us  almost  a 
C)  clopasdia  within  the  limits  of  aconvenient  volume, 
and  has  done  so  without  penning  the  useless  para- 
graphs too  commonly  making  up  a  great  part  of  the 
bulk  of  many  cumbrous  works.  The  progressive 
scientist  is  not  disappointed  when  he  looks  for  the 
record  of  new  and  valuable  processes  and  discover- 
ies, while  the  cautious  conservative  does  not  find  i  ts 
pages  monopolized  by  uncertain  theories  and  specu- 
lations. A  peculiar  point  of  excellence  is  the  crys- 
tallized form  of  expression  in  which  great  truths  are 
expressed  in  very  short  paragraphs.  One  is  surprised 
at  the  brief  space  allotted  to  an  important  topic,  and 
yet,  after  reading  it,  he  feels  that  little,  if  any  more 
should  have  been  said.  Altogether,  it  is  seldom  yo i 
see  a  text-book  so  nearly  faultless.  —  Cincinriati 
Lancet  Nov.  1873. 


ffLO  WES  (FRANK),  D.Sc.  London. 

^S  Senior  Science-Waster  atthe  High  School,  tfeweastle-under  Lyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Laboratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth.  $2  50.     (Just  Issued.) 


ft  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commend  it  to  students,  and  espe- 
cially to  those  who  are  obliged  to  dispense  with  a 
master.  Of  course,  a  teacher  is  in  every  way  desi- 
rable, but  a  good  degree  of  technical  skill  and  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St.  Louis  Glin.  Record,  Oct. 
1877. 

The  work  is  so  written  and  arranged  that  it  can  be 

omprehended  by  the  student  without  a  teacher,  aud 

the  descriptions  and  directions  forthe  various  work 


are  so  simple,  and  yet  concise,  as  to  be  interesting 
and  intellig'ble.  The  work  is  unincumbered  with 
theoretical  deductions,  dealing  wholly  with  the 
practical  matter,  which  it  is  the  aim  of  this  compre- 
hensive text-book  to  impart.  The  accuracy  of  the 
analytical  methods  are  vouched  for  from  the  fact 
that  they  have  all  been  worked  through  by  the 
author  and  the  members  of  his  class,  from  the 
printed  text.  We  can  heartily  recommend  the  work 
to  the  student  of  chemistry  as  being  a  reliable  and 
comprehensive  one. — Druggists'  Advertiser,  Oct. 
15,  1S77. 


KNiPP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  Walter  K.  Johnson.     In  two 


very  handsome  octavo  volumes,  with  500  wood 
engravings, cloth,  $6  00. 


OARRISH  [EDWARD), 

Late  Professor  of  Materia  Medicainthe  Philadelphia  College  of  Pharmacy . 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  and 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  Thomas  S.  Wiegand.  In  one 
ha  ndsnme  octavo  volume  of  977  pages,  with  280  illustrations  ;  cloth.  $5  50  ;  leather,  $6  50; 
half  Russia,  $7.     (.Lately  Issued.) 

the  work,  not  only  to  pharmacists,  but  also  to  the 
multitude  of  medical  practitioners  who  are  obliged 
to  compound  their  own  medicines.  It  will  ever  hold 
an  honored  place  on  our  own  bookshelves. — Dublin 
Med.  Press  and  Circular,  Aug.  12,  1874. 


Of  Dr.  Parrish's  great  work  on  pharmacy  it  only 
remains  to  be  said  that  the  editor  has  accomplished 
his  work  so  well  as  to  maintain,  in  this  fourth  edi- 
tion, the  high  standard  of  excellence  which  it  bad 
attainedin  previous  editions,  undertheeditorship  of 
its  accomplished  author.  This  has  not  been  accom- 
plished without  much  labor, and  many  additions  and 
improvements,  involving  changes  in  the  arrange- 
ment of  the  several  parts  of  the  work,  and  the  addi-  to  detract  from  that  opinion  in  reference  to  the  pre- 
tion  of  much  new  matter.  With  the  modifications'  sent  edition,  the  preparation  of  which  has  fallen  into 
thus  effected  it  constitutes,  as  now  presented ,  a  com- !  competent  hands.  It  is  a  book  with  which  no  pharma- 


We  expressed  our  opinion  of  a  former  edition  in 
terms  of  unqualified  praise,  and  we  are  in  no  mood 


cist  can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  and  Surg.  Journ.,  June,'74. 

Perhaps  one,  if  not  the  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"  Parrish's  Pharmacy"  is  a  well-known  work  on  this 
merit  of  being  readable  and  interesting,  while  it  pre- !  side  ofthe  water,  and  the  fact  shows  us  that  a  really 
serves  astrictlyscientificcharacter.  The  whole  work  '■  useful  work  neverbecomes  merely  local  in  its  fame, 
reflects  the  greatest  credit  on  author,  editor  and  pub-  j  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
Usher.  It  will  con  vey6o  me  idea  of  the  liberality  which  I  posthumous  edition  of  "Parrish"  has  been  saved  to 
has  been  bestowed  upon  its  production  when  we  men-  the  public  with  all  the  mature  experience  of  its  an- 
tion  that  there  are  no  less  than  2S0  carefully  executed  thor,  and  perhaps  none  the  worse  for  a  dash  ofnew 
illustrations.  In  conclusion,  we  heanily  recommend   blood. — Lond.  Pharm.  Journal,  Oct.  17, 1874. 


pendium  ofthe  science  and  art  indispensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practitioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  ofthe 
articles  which  he  prescribes  for  his  patients. — Chi- 
cago Med.  Journ.,  July,  1874. 

The  work  is  eminently  practical,  and  has  the  rare 


12  Henry  C.  Lea's  Son  A  Co. '8  Publications — (Mat  Med.and  Therap.). 


ffARQUHARSON  (ROBERT),  M.D., 

Lecturer  on  Materia  Medico,  at  St.  Mary' s  Hospital  Medical  School. 


A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.    Se- 

cond  American  edition,  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S. 
Pharmacopoeia.  I5y  Frank  Woodbuky,  M.D.  In  one  neat  rojal  12mo.  volume  of  498 
pages:  oloth,  $2.25.     {Just  Ready.) 


The  appearance  of  a  uew  edition  of  this  con  ve-  I 
nient  and  handy  book  in  less  than  two  years  may  ! 
certainly  be  taken  as  an  indication  of  its  useful 
ness.  Its  convenient  arrangement,  and  its  terse-  | 
ness,  and,  at  the  same  time,  completeness  of  the 
information  given,  make  it  a  handy  book  of  refer-  i 
ence. — Am.  Journ.  of  Pharmacy,  June,  1879. 

This  work   contains  in  moderate   compass  .such 
well-digested    facts    concerning   the  physiological  I 
and  therapeutical  action  of  remedies  as  are  reason-  ! 
ably  established  up  to  the  present  time.    By  a  con- 
venient arrangement  the  corresponding  effects  of' 
each  article  in  health  and  disease  are  presented  in 
parallel    columns,   not  onjy  rendering    reference 
easier,  but  also  impressing  the  facts  more  strongly  j 
upon  the  mind  of  the  reader.    The  book  has  been 
adapted  to  the  wants  of  the  American  student,  and  | 


copious  notes  have  been  introduced,  embodying  the 
latest  revision  of  tve  Pharmacopoeia,  together  wi  h 
the  antidotes  to  the  more  prominent  poisons,  and 
such  of  the  newer  remedial  agents  as  seemed  neces- 
sary to  the  completeness  of  the  work.  Tables  of 
weights  and  measures,  and  a  good  alphabetical  in- 
dex end  the  volume. — Druggists'  Circular  and 
Chemical  Qatelte,  June,  1679. 

It  is  a  pleasure  to  think  that  the  rapidity  with 
which  a  second  edition  is  demanded  may  be  taken 
as  an  indication  that  the  sense  of  appreciation  of  the 
value  of  reliable  information  regarding  the  use  of 
remedies  i-  not  entirely  overwhelmed  in  the  cultiva- 
tion of  pathological  studies,  characteristic  of  the  pre- 
sent day.  This  work  certainly  merits  the  success  it 
has  so  quickly  achieved. —  New  Remedies,  July,  '79. 


&TILLE  (ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols,  of  about  2000 
pages.     Cloth,  $10;  leather,  $12;  half  Russia,  $13.     {Lately  Issued.) 


It  is  unnecessary  to  do  much  more  than  to  an-  . 
nounce  the  appearance  of  the  fourth  edition  of  this  j 
well  known  and  excellent  work. — Brit,  and  For. 
Med.-Chir.  Review,  Oct.  Ib75. 

Forallwhodesireacomplete  workon  therapeutics 
and  materia  medicafor  reference,  in  cases  involving 
medico-legal  questions,  as  well  as  for  information 
concerning  remedial  agents.  Dr.  stille"s  is  "par  ex- 
cellence" the  work.  The  work  being  out  of  print,  by 
the  exhaustion  of  former  editions,  t  he  author  has  laid 
the  profession  under  renewed  obligations,  by  the 
careful  revision,  important  additions,  and  timely  re 
issuing  a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publisher.— 
St.  Louis  Med.  and  Surg.  Journal,  Dec.  1874. 

From  the  publication  of  the  first  edition  "Stilll's 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacuum 
which  could  be  filled  by  no  other  work  in  the  lan- 
guage, and  its  presence  supplies, in  the  two  volumes 


of  the  present  edition,  a  whole  cyclopaedia  of  thera- 
peutics.— Chicago  Medical  Journal,  Feb.  1S75. 

The  rapid  exhaustion  of  three  editions  and  the  uni- 
versal favor  with  which  the  work  has  been  received 
by  the  medical  profession,  are  sufficient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  us 
fully  sustain  s  this  verdict,  as  the  work  has  been  care- 
fully revised  and  in  some  portions  rewritten,  bring- 
ing it  up  to  the  present  time  by  the  admission  of 
chloral  and  croton  chloral,  nitrite  of  amyl,  bichlo- 
ride of  methylene,  methylic  ether,  lithium  com- 
pounds, gelseminum,  and  other  remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  1875. 

We  can  hardly  admit  that  it  has  a  rival  In  the 
multitude  of  its  citations  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  iu  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  state  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston  Med.  and.  Surg.  Journal,  No  v.  6, 
1874. 


(7RIFFITH  (ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  1>3  John  M. 
Ma  isc  h.  Professor  of  Materia  Medicain  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  800pp.,  cl.,  $460  ;  leather,  $5  50.  {Lately  Issued.) 


To  the  druggist  a  good  formulary  is  simply  indis- 
pensable, and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 
us.  Many  physicians  have  to  officiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teacb  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  its  place  upon  his  shelf.  A  formulary  of 
this  kind  is  of  benefit  also  to  the  city  physician  in 
largest  practice.— Cincinnati  Clinic,  Feb.  21.  1874. 


A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  less  essential  to  the  practitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  onght  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  fonnd  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  '74. 


CHRI8TISON'S  DISPENSATORY.  With  copious  ad- 
ditions, and  213  large  wood  engravings.  By  R 
E'ji.f.spifi.d  Griffith,  M.D.  One  vol.  8vo.,  pp. 
1000,  cloth.    «4  00. 


CARPENTER'S  PRIZE  ESSAT  ON  THE  USE  OF 
Alcoholic  Liquors  ik  Health  ahd  Disbasr.  New 
edition,  with  a  Preface  by  D.  F.  Coxdir.  M.D.,and 
explanations  of  scientific  words.  In  oneneat  )2mo. 
volume,  pp.  178,  cloth.    60  cents. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Mat.  Med.  and  Therap.).  13 
CITILLE  (ALFRED),  M.D.,  LL.P.,  and  IfAlSCH  (JOHN  M.),  Ph.D.. 

O        Prof,  of  Theory  and  Practice  of  Medicine  -L'-L        Prof,  of  Mat.  Mud.  and  Hot  in  I'hila, 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  Pharmacy ,  Secy,  to  the  American 

Pharmace.ut ica. I  AxitociaJion. 

THR   NATIONAL  DISPENSATORY:  Containing  the  Natural  Tlistory, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in 
the  Pharmacopoeias  of  the  United  Stntes,  Great  Britain,  and  Germany,  with  numer- 
ous references  to  the  French  Codex.  Second  edition,  thoroughly  revised,  with  numerous 
additions.  In  one  very  handsome  octavo  volume  of  1 692  pages, with  239  illustrations. 
Extra  cloth,  $6  75  ;  leather,  raised  bands,  $7  50  ;  half  Russia,  raised  bands  and  open 
back,  $8  25.     (Now  Ready  ) 

Preface  to  the  Second  Edition. 

The  demand  which  has  exhausted  in  a  few  months  an  unusually  large  edition  of  the  National 
Dispensatory  is  doubly  gratifying  to  the  authors,  as  showing  that  t'ley  were  correct  in  thinking 
that  the  want  of  such  a  work  was  felt  by  the  medical  and  pharmaceutical  professions,  and  that 
their  efforts  to  supply  that  want  have  been  acceptable.  This  appreciation  of  their  labors  has 
stimulated  them  in  the  revision  to  render  the  volume  more  worthy  of  the  very  marked  favor 
with  which  it  has  been  received.  The  first  edition  of  a  work  of  such  magnitude  must  necessarily 
be  more  or  less  imperfect ;  and  though  but  little  that  is  new  and  important  has  been  brought 
to  light  in  the  short  interval  since  its  publication,  yet  the  length  of  time  during  which  it  was 
passing  through  the  press  rendered  the  earlier  portions  more  in  arrears  than  the  la'er.  The 
opportunity  for  a  revision  has  enabled  th«  authors  to  scrutinize  the  work  as  a  whole,  and  to 
introduce  alterations  and  additions  wherever  there  has  seemed  to  be  occasion  for  imorove- 
ment  or  greater  completeness.  The  principal  changes  to  be  noted  are  the  introduction  of  seve- 
ral drugs  under  separate  headings,  and  of  a  large  number  of  drugs,  chemicals,  and  pharma- 
ceutical preparations  classified  as  allied  drugs  and  preparations  under  the  heading  of  more 
important  or  better  known  articles:  these  additions  comprise  in  part  nearly  the  entire  German 
Pharmacopoeia  and  numerous  articles  from  the  French  Codex.  All  new  investigations  which 
came  to  the  authors1  notice  up  to  the  time  of  publication  have  received  due  consideration. 

The  series  of  illustrations  has  undergone  a  corresponding  thorough  revision.  A  number  have 
been  added,  and  still  more  have  been  substituted  for  such  as  were  deemed  less  satisfactory. 

The  new  matter  embraced  in  the  text  is  equal  to  nearly  one  hundred  Dages  of  the  first  edition. 
Considerable  as  are  these  changes  as  a  whole,  they  have  been  accommodated  by  an  enlargement 
of  the  page  without  increasing  unduly  the  size  of  the  volume. 

While  numerous  additions  have  been  made  to  the  sections  which  relate  to  the  physiological 
action  of  medicines  and  their  use  in  the  treatment  of  disease,  great  care  has  been  taken  to 
make  them  as  concise  as  was  possible  without  rendering  them  incomplete  or  obscure.  The 
doses  have  been  expressed  in  the  terms  both  of  troy  weight  and  of  the  metrical  system,  for  the 
purpose  of  mak'ng  those  who  employ  the  Dispensatory  familiar  w.th  the  latter,  and  paving  the 
way  for  its  introduction  into  general  use. 

The  Therapeutical  Index  has  been  extended  by  about  2250  new  references,  making  the  total 
number  in  the  present  edition  about  6000. 

The  articles  there  enumerated  as  remedies  for  particular  diseases  are  not  only  those  which, 
in  the  authors'  opinion,  are  curative,  or  even  beneficial,  but  those  also  which  have  at  any  time 
been  employed  on  the  ground  of  popular  belief  or  professional  authority.  It  is  often  of  as 
much  consequence  to  be  acquainted  with  the  worthlessness  of  certain  medicines  or  with  the 
narrow  limits  of  their  power,  as  to  know  the  well  attested  virtues  of  others  and  the  conditions 
under  which  they  are  displayed.  An  additional  value  posse  sed  by  such  an  Index  is.  that  it 
contains  the  elements  of  a  natural  classification  of  medicines,  founded  upon  an  analysis  of  the 
results  of  experience,  which  is  the  only  safe  guide  in  the  t.reacinent  of  disease. 

This  evidence  of  success,  seldom  paralleled,  '■  intend  to  let  the  grass  grow  under  their  feet,  but  to 
shows  clearly  how  well  the  authors  have  met  the  keep  the  work  up  to  the  time. — New  Remedies,  Nov. 
existing  needs  of  the  pharmaceutical  and  medical  ,  1879. 

professions.  Gratifying  as  it  must  be  to  them,  they  !  Thi,  ig  a  t  work  b  tw0  of  the  ablegt  writers  on 
have  embraced  the  opportunity  offered  for  a  thor-  ;  raaterla  m£,ica  in  Ameriea  The  authors  h»ve  pro- 
ough  revision  of  the  whole  work,  striving  to  em-  i  dueed  a  work  which  for  accuracy  and  comprehensive- 
brace  within  if  all  that  might  have  been  omitted  in  :  negs,  is  unsurpassed  by  any  work  on  the  subject.  There 
the  former  edition,  and  all  that  has  newly  appeared  ig  no  book  in  the  English  language  which  contains  so 
of  sufficient  importance  during  the  time  of  its  col-  much  vaU,abie  information  on  the  various  articles  of 
lahoration,  and  the  short  interval  elapsed  since  the  tne  materja  medica.  The  work  has  cost  the  authors 
previous  publication.  After  having  gone  carefully  years  of  laborious  study,  but  they  have  succeeded  in 
through  the  volume  we  must  admit  that  the  authors  produejng  a  dispensatory  which  is  not  only  national, 
have  labored  faithfully,  and  with  success,  in  mam-  but  will  be  a  lasting  memorial  of  the  learning  and 
taining  the  high  character  of  their  work  as  a  com-  ;  abllitv  of  the  authors  who  produced  it.— Edinburgh 
pendium   meeting  the  requirements  of  the  day,  to  ;  MedicalJournal,  Nov.  1879. 


which  one  can  safely  turn  in  quest  of  the  latest  in 
formation  concerning  everything  worthy  of  notice  in 
connection  with  Pharmacy,  Materia  Medica,  and 
Therapeutics. — Am.  Jour,  of  Pharmacy,  Nov.  1879. 
It  is  with  great  pleasure  that  we  announce  to  our 
readers  the  appearance  of  a  second  edition  of  the 
National  Dispensatory.  The  total  exhausiion  of  the 
first  edition  in  the  short  space  of  six  months,  is  a 
sufficient  testimony  to  the  value  placed  upon  the 
work  by  the  profession.  It  appears  that  the  rapid 
sale  of  the  first  edition  must  have  induced  both  the 
editors  and  the  publisher  to  make  preparations  for 
a  new  edition  immediately  after  the  first  had  been 
issued,  for  we  find  a  large  amount  of  new  matter 
added  and  a  good  deal  of  the  previous  text  altered 
and  improved,  which  proves  that  the  authors  do  not 


It  is  by  far  more  international  or  universal  than 
any  other  book  of  the  kind  in  our  language,  and 
more  comprehensive  in  every  sense. — Pacific  Med, 
and  Surg.  Jown.,  Oct.  1879. 

The  National  Dispensatory  is  beyond  dispute  the 
very  best  authority.  It  is  throughout  complete  in 
all  the  necessary  details,  clear  and  lucid  in  its  ex- 
planations, and  replete  with  references  to  the  most 
recent  writings,  where  further  particulars  can  be 
obtained,  if  desired.  Its  value  is  greatly  enhanced 
by  the  extensive  indices — a  general  in<  ex  of  materia 
medica,  etc.,  and  also  an  index  of  therapentics  It 
would  be  a  work  of  supererogation  to  say  mora  about 
this  well-known  work.  No  practising  physician  can. 
afford  to  be  without  the  National  Disoen^atory.— 
Canada  Med.  and  Surg.  Journ.,  Feb.  18S0. 


14        Henry  C.  Lea's  Son  &  Co.'s  Publications — {Pathology,  &c). 


ftANVIER  (L.). 

■*■  ™        Prof  in  the  College  of  Prance. 


(10RNIL  (V.),  AND 

^        Prof,  in  the  Faculty  of  Med.,  Paris. 

MANUAL  OP  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Note?  and  Additions,  by  E.  0.  Shakespeare,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Pbilada.  Hospitnl,  Lecturer  on  Refraction  and  Operative  Ophthalmic  Surgery  in  Univ. 
of  Penna.,  and  by  HEKRr  C.  Simks.  M  D.,  Demonstrate r  of  Pathological  Histology  in 
the   Univ.  of  Pa.     In  one  very  handsome  octavo  volume  of  over  700  pages,  with  over 
350  illustrations.     Cloth,  $5  50;  leather,  $6  50;  half  Russia,  $7.     (Just  Ready.) 
The  work  of  Cornil  and  Ranvier  is  so  well  known  as  a  lucid  and  accurate  text-book  on  its 
important  subject,  that  no  apology  is  needed  in  presenting  a  translation  of  it  to  the  American 
profession.     It  is  only  necessary  to  say  that  the  labors  of  Drs.  Shakespeare  and  Simes  have 
been  by  no  means  confined  to  the  task  of  rendering  the  work  into  English.     As  it  appeared  in 
France,  in  successive  portions,  between  1868  and   1876,  a  part  of  it,  at  least,  was  somewhat  in 
arrears  of  the  present  state  of  science,  while  the  diffuseness  of  other  portions  rendered  conden- 
sation desirable.     The  translators  have,  therefore,  sought  to  bring  the  work  up  to  the  day, 
and,  at  the  same  time,  to  reduce  it  in  size,  &i  far  as  practicable,  without  impairing  its  com- 
pleteness     These  changes  will  be  found  throughout  the  volume,  the  most  extensive  being  in 
the  sections  devoted  to  Sarcoma,  Carcinoma,  Tuberculosis,  the  Bloodvessels,  the  Mammae,  and 
the  classification  of  tumors      Corresponding  modifications  have  been  made  in  the  very  exten 
sive  and  beautiful  series  of  illustrations,  and  every  care  has  been  taken  in  the  typographical 
execution  to  render  it  one  of  the  most  attractive  volumes  which  have  issued  from  the  American 
press. 

We  have  n  >  hesitation  in  cordially  recommending  |  Their  book  Is  not  a  collection  of  the  work  of  others, 
the  English  translation  of  Cornil  &  Kanvier's  "Pa-  ;  but  has  been  written,  in  the  laboratory  beside  the 
thological  Histology"  as  the  best  work  of  the  kiod  i  microscope.  It  bears  the  marks  of  personal  knowl- 
in  any  language,  and  as  giving  to  its  readers  a  I  edge  and  investigation  npon  every  page,  controlled 
trustworthy  gaide  in  obtalniog  a  broad  and  solid  '  by  and  controlling  the  work  of  others.     ...     In 


basis  for  the  appreciation  of  the  practical  bearings 
of  pathological  anatomy. — Am.  Journ.  of  Med. 
Sciences,  A  >ril,  1SS0. 

This  important  work,  in  it«  American  dress,  is  a 
welcome   offering  to  all  stndenis  of   the   subjects 


short,  its  translation  has  made  it  the  best  work  in 
pathology  attainable  in  our  language,  one  that  every 
■undent  certainly  ought  to  have. — Archives  of  Med- 
icine, April,  1SS0. 
This  work,  in  the  original,  has    for   years  past 


F 


which  it  treats.  The  great  mass  of  material  is  I  occupied  a  prominent  place  in  the  library  of  French 
arranged  naturally  and  comprehensively.  The  j  pathologists,  as  we  should  naturally  be  led  to  be- 
classification  of  tumors  is  clear  and  full,  so  far  as  lieve  from  the  reputation  of  the  distinguished  »u- 
the  subject  tdinits  of  definition  and  this  one  chap-  I  thors  Now  that  it  has  been  presented  to  the  Eng- 
ter  is  worth  the  price  of  the  bock  The  il lustra-  j  lish  student  for  the  first  time,  it  will  be  perused 
tioos  are  copious  and  well  chosen.  Without  the  '  with  unusual  interest.  The  illustrations  are  by  no 
slightest  hesitation,  the  translators  deserve  honest  !  means  the  least  valuable  part  of  the  work.  Indie- 
thanks  for  placing  this  indispensable  work  in  the  !  pensable  as  they  are  to  any  work  of  this  nature, 
hands  of  American  students. — Phila.  Med.  Times,  ]  in  the  work  before  us  the  artist  has  succeeded  in 
April  24,  1880  producing  cuts  which  will  prove  unusually  valuable 

This  volume  we  cordially  commend  to  the  profes-     t0  the  rea,der-    The  translation  is  well  done,  and 
sion.     It  will  prove  a  valuable,  almost  necessary,  '  «i,re8  evidence  throughout     he  volume  that  it  was 
addition  to  the  libraries  of  students  who  are  to  be  j  m*de  by  '/«  ?°A°a% 'V^or^bSo 
physicians,  and  to  the  libraries  of  students  who  are    subject.-^,  y.  Med.  Gazette,  Feb.  28, 18S0. 
pbysicia is.—  American  Practitioner,  June,  1880      I 

EN WICK  ( SA  M UEL) ,  M.D., 

Axsistant  Phyxicinn  to  the  London  Hospital. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition.     With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  1 2mo. ,  cloth,  $2  25.     {Just  Issued.) 

SCREEN  (T.  HENRY),  M.D., 

V^"  Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Croxs  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American, from 

the  Fourth  and  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo 
volume  of  332  pages,  with  132  illustrations;  cloth,  $2  25.     (Now  Ready.) 

This  Is  unquestionably  one  of  the  best  manuals  on  ciently  numerous,  and  usually  well  made.  In  the 
the  subject  of  pathology  and  morbid  anatomy  that  present  edition,  such  new  mailer  has  been  added  as 
can  be  placed  in  the  student's  hands,  and  we  are  was  necessary  to  embrace  the  later  resnlts  in  patfao- 
giad  to  see  it  kept  up  to  the  times  by  new  editions,  logical  research.  No  doubt  it  will  continue  to  enjoy 
Each  edition  is  carefully  revised  by  the  author,  with  the  favor  it  has  received  at  the  hands  of  the  protes- 
the  view  of  making  it  include  the  most  recent  ad-  sion. — Med  and  Surg.  Reporter,  Feb.  1,  1879. 
vances  in  pathology,  and  of  omitting  whatever  may  <  For  practical,  ordinary  dally  use,  this  is  nndouht- 
have  become  obsolete.—  -A.  T.  Med.  Jour.,  reb.  Ibid.    edljr  the  be(jt  treatise  that  is  offered  to  students  of 

The  treatise  of  Dr.  Green  i«  compact,  clearly  ex-    pathology  and  m  irbld  anatomy. — Cincinnati  Lan- 
pressfd,  up  to  the  times,  and  popular  as  a  text-book,    cet  and  Clinic,  Feb.  8,  1879. 
both  in  England  and  America.    The  cuts  are  snffl- 

G  LUGE'8  ATLA8  of  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  Joseph 
Lbidt,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  $4  00. 
PaVY'«  TREATI8E  ON  THE  FUNCTION  OF  DI- 
GESTION: its  Di»orders  aod  their  Treatment. 
From  the  second  London  edition  In  one  band- 
some  volnme,  small  octavo,  cloth,  $2  00. 
LA  ROCHE  ON  YELLOW  FEVER. considered  In  its 
Historical.  Pathological.  Etiological,  and  Thera 
peutical  Relations.  In  two  large  and  handsome 
octave  volumes  of  near.'y  1500  pp  , cloth.    $7  00. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS.   1  vol.  8 vo.,  pp.  500,  cloth.    iS  60. 

BARLOWS  MANDAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  CoitBJR 
M    D.    lvol.8vo.,  pp  600.  cloth.    $2  50 

TODD'SCLINICALLBCTORESON  CERTAIN  ACUTE 
Disease.-;.  In  one  neat  octavo  volume,  of  320  pp  , 
cloth.    *2  «n 

STORES'  LECTURES  ON  FEVER  Edited  by  Job* 
Wii.i.i  ax  Moork,  M.  D..  A»8ifltaot  Physician  to  the 
('  Tk  Street  Fever  Hospital.  In  one  neat  8vo. 
vo.uuie   cloth,  $2  00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — {Practice  of  Medicine).  15 
fiTLINT  (A  USTIN),  M.D., 

■*■  Prof  elisor  of  I  he  Principle*  and  Practice  of  Medicine  in  Bellevue  Med .  College,  tf.  T. 

A   TREATISE    ON   THE    PRINCIPLES  AND   PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fifth 
edition,  entirely  rewritten  and  much  improved.  In  one  large  and  closely  printed  octavo 
volume  of  about  1100  pp.     ([n  press  ) 

EXTRACT  FROM  THK  AUTHOR'S  PREFACE. 

In  preparing  the  fifth  edition  of  this  treatise,  the  author  has  been  thorouthly  mindful  of  the 
progress  of  medicine  since  the  publication  of  the  fourth  edition  in  1873.  Time  and  labor  have 
not  been  spared  in  the  endeavor  to  briag  the  work  in  all  respects  up  to  the  present  state  of 
medical  knowledge. 

Dr.  William  H.  Welch,  Lecturer  on  Pathological  Histology  in  the  Bellevue  Hospital  Medical 
College,  has  contributed  in  Part  I  the  first  S9ven  chapters,  embracing  the  general  pathology  of 
the  solid  tissues  and  of  the  blood.  He  has  also  revised,  and  in  great  part  rewritten,  the  descrip 
tions  of  the  anatomical  characters  of  the  diseases  considered  in  the  rest  of  the  volume  It  is 
believed  that  these  portions  of  the  work  will  serve  as  a  digest  of  the  essential  facts  pertaining  to 
general  and  special  pathological  anatomy,  as  far  as  this  important  branch  of  study  bears  upon 
practical  medicine 

In  the  other  portions  of  the  treatise  many  changes  will  be  found,  which  have  somewhat  en- 
larged the  size  of  the  volume,  in  spite  of  the  omission  of  a  considerable  amount  of  matter,  and 
the  rewriting  of  many  portions  with  a  special  view  to  condensation.  Among  these  changes  may 
be  mentioned  numerous  improvements  in  the  arrangement,  including  the  cla-sificat'on  of  the 
diseases  of  the  nervous  system  on  an  anatomical  in  place  of  a  symptomatic  basis,  and  the  con- 
sideration of  various  disea.-es  not  embraced  in  previous  editions.  In  short,  the  eliminations, 
substitutions,  and  additions  render  the  present  edition  virtually  a  new  work. 

In  making  changes,  the  author  has  not  been  influenced  by  any  sense  of  obligation  to  maintain 
consistency  of  views  with  the  previous  editions  of  this  treatise,  or  with  other  works  which  he  has 
written.  If  statements  be  found  to  vary  from  those  made  at  a  prior  date,  the  simple  explana- 
tion is  that  the  latter,  in  the  light  of  more  recent  reflection  and  enlarged  knowledge,  seems  to 
him  no  longer  tenable.  He  has  endeavored  to  regard  his  own  past  writings,  in  this  point  of 
view,  divested  of  the  partiality  of  authorship,  and  to  subject  them  to  as  critical  an  examination 
as  if  they  were  the  writings  of  another. 


Df  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;   a  Systematic   Treatise  on    the  Diagnosis 

nnd  Treatment  of  Diseases.     Designed  for  Students  and  Practitioners  of  Medicine.     In 
one  large   and  handsome   octavo  volume  of  795  pages;  cloth,  $4   50  ;  leather,  $5  50; 
half  Russia,  $6.      (Now  Ready.) 
The  eminent  teacher  who  has  written  the  volume  [      It  is  here  that  the.  skill  and  learning  of  the  great 
under  consi  leratiou   h:s  recognized   the   needs  of  I  clinician  are  displayed      He  ha*  given   us  a  store- 
the  American  profession,  and  the  result  is  all  that  \  house  of  medical  knowledge,  excellent  for  the  stu- 
we  could  wish.     The  style  in  which  it  i-  writien  is  j  dent,  convenient  for  the  praciitioner,  the  result  of  a 
peculiarly  the  author's;  it  is  clear  and  forcible,  and  j  loag  life  of  the  most  faithful  clinical  work,  collect- 
marked  by  those  characteristics  which   have  ren- !  ed  by  an  energy  as  vigilant  and  systematic  as  un- 
dered  him  one  of  the  best  writers  and  teachers  this  i  tiring,  and  weighed   by  a  judgment   no  less  clear 
country  has  ever  produced.    We  have  not  space  for     than  his  observation  is  close.— Archives  of  Medi- 
na full  a  consideration  of  this  remarkable  work  as    cine,  Dec.  1S79. 
we  would  desire. — S.  Louis  Clin.  Record,  Oct.  1879.  i 


W: 


jgF  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE    MEDICINE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  12mo.  volume.     Cloth,  $1  38.     (Just  Issued.) 

'A  TSON  (  THOMAS),  M.D.,  frc. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
tions,  by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn  - 
sylvania.  In  two  large  and  handsome  8vo.  vols.  Cloth,  $9  00  ;  leather,  $11  00.  (Lately 
Published.) 

fJARTSHORNE  {HENRY),  M.D., 

*-■*-  Professor  of  Hygiene  in  the  University  of  Pennsylvania 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDI- 
CINE. A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  12mo.  volume, 
of  about  550  pages,  cloth,  $2  63;  half  bound,  $2  88.     (Lately  Issued.) 

DAVIS'S    CLINICAL     LECTURES     ON    VARIOUS  I      eases  of  Women  and  Children.  Medical  Jurispru- 

IMPORTANT  DISEASES;  being  a  collection  of  the  dence,  etc.  etc.     By  Dunoi.ison,  Forbes,  Tweedie, 

Clinical  L-ctures  delivered  in  the  Medical  Wards  and   Conollv.    In   four  large  super-royal  octavo 

of  Mercy  Hospi  a),  Chicago.     Edited  by  Frank  H  volumes,  of  3254  double-columned  piges,  strongly 

Davis,  M.  D.     Second   edition,   enlarge!.     In    one  and  handsomely  bound  in  leather.  $15;  cloth.  *U 
baudsome  royal  12oao.  volume.     Cloth,  $1  75.             STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 

THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE:  CLINICAL  MEDICINE.     Being  a  Guide  to  the  In- 

c  >mprising  Treatises  on  the  Nature  and  Treatment  vestigation  of   Disease.     In  one  handsome   12mo. 
of  Diseases,  Materia  Medica  and  Therapeutics,  Dis-  1      volume,  cloth,  *1  25.    (Lately  Issued.) 


16    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Practice  of  Medicine). 
DRISTO  WE  [JOHN  SFER),  M.D.,  F.R.C.P., 

J-s  Physician  and  Joint  Lecturer  on  Medicine,  St.  Thomas'*  Hospital. 

A    TREATISE    ON    THE    PRACTICE    OF    MEDICINE.     Second 

American  edition,  revised  by  the  Author.   Edited,  with  Additions,  by  James  H.  Hutch- 
inson, MD.,  Physicinn  to  the   Penna.  Hospital.     In  one  handsome  octavo  volume  of 
nearly  1200  pages.      With  illustrations.     Cloth,  $5  00;   leather,  $6  00;  half  Russia, 
$6  50.     (Now  Ready.) 
The  second  edition  of  this  excellent  work,  like  the,  from  the  beet  sources  outside  of  the  author's  own 
first,  has  received   the  benefit  of  Dr.  Hutchinson's    long  experience,  and  the  valuable  portion  relating 
annotations,  by  which  the  phases  of  disease  which  \  >o  general  pathology,  aid  greatly  in  completing  an 
are  peculiar  to  this  country  are  indicated,  and  thns  j  exceptionally  good  book  for  purposes  of  reference 
a   treatise   which  was  intended  for   British   practi-  i  and   ins  ruction  — Boston    Medical  and  Surgical 
turners  and' students  is  made  more  practically  nstfnl  |  Journal,  Febrnary,  18S0. 

on  this  side  of  the  water.  We  see  no  reason  to  j  what  we  gaid  of  the  firgt  eduion(  we  can,  with 
modify  the  higb i  opinion  previously  expressed with!  increased  emphasis,  repeat  concerning  this:  "Every 
regard  to  Dr.  Bristowe's  work  except  by  adding  j  page  is  characterized  b y  the  utterances  of  a  thought- 
our  appreciation  of  the  careful  labors  of  the  author  |  fn,  miu  What  hag  b^en  saW  bag  been  wel,  gaid 
in  following  the  lateral  growth  of  medical  science.  and  the  book  ig  a  fair  reflex  of  all  lhat  u  ceHainly 
The  chapter  on  diseases  of  the  skin  and  of  the  nerv-  \  knnwn  on  the  snbiects  considered. "-OAio  Med. 
ous  system,  with  a  new  one  on  insanity  compiled  I  Rec0rder  Jan.  7  1880 

L>ICHARDSON[BENJ.  TV),  M.D.,  F.R.S.,  M.A.,  LL.D.,  F.S.A., 

•*-  **        Fellow  of  the  Royal  College  of  Physicians,  London. 

PREVENTIVE  MEDICINE.    In  one  octavo  volume  of  about  500  pages. 

(In  Press.) 

The  immense  strides  taken  by  medical  science  during  the  last  quarter  of  a  century  have  had 
no  more  conspicuous  field  of  progress  than  the  causation  of  disease.  Not  only  has  this  led  to 
marked  advance  in  therapeutics,  but  it  has  given  rise  to  a  virtually  new  department  of  medi- 
cine— the  prevention  of  disease — more  important,  perhaps,  in  its  ultimate  results  than  even  the 
investigation  of  curative  processes.  Yet  thus  far  there  has  been  no  attempt  to  gather  into  a 
systematic  and  intelligible  shape  the  accumulation  of  knowledge  thus  far  acquired  on  this  most 
interesting  subject.  Fortunately,  the  task  h°s  been  at  last  undertaken  by  a  writer  who  of  all 
others  is,  perhaps,  best  qualified  for  its  performance,  and  the  result  of  his  labors  can  hardly  fail 
to  mark  an  epoch  in  the  history  of  medical  science.  The  plan  adopted  for  the  execution  of  this 
novel  design  can  best  be  explained  in  his  own  words  : — 

"With  the  object  here  expressed  I  write  this  volume.  I  have  nothing  to  say  in  it  that  has 
any  relation  to  the  cure  of  disease,  but  I  base  it  revertheless  on  the  curative  side  of  medical 
learning  In  other  words,  I  trace  the  diseases  from  their  actual  representation  as  they  exist 
before  us,  in  their  natural  progress  after  their  birth,  as  far  as  I  am  able,  back  to  their  origins, 
and  try  to  seek  the  conditions  out  of  which  they  spring.  Thereupon  I  endeavor  further  to 
analyze  those  conditions,  to  see  how  far  they  are  removable  and  how  far  they  are  avoidable." 

POTHERGJLL  (J.  MILNER),M.D.  Edin.,  M.R.C.P.  Lo-nd.. 

-*-  Asst.  Phys.  to  the  West  Lond  Hosp. :  Asst.  Phys.  to  the  City  of  Lond*Hosp.,etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     Second  edition,  revised  and  enlarged.     In  one  very  nent 
octavo  volume  of  about  650  pages.     Cloth,  $4  00;  very  handsome  half  Russia,  $5,  50. 
(Just  Ready.) 
Th»  call  for  a  second  edition  of  Dr.  Fothergill's  work  has  been  met  by  the  author  with  a 
revision  performed  in  no  perfunctory  manner.     The  entire  subject-matter  hns  been  submitted 
to  a  most  careful  and  exhaustive  scrutiny,  and  much  new  material  been  added,  including  articles 
on  "The  Functional  Disturbances  of  the  Liver,"   "The  Means  of  Acting  on  the  Respiratory 
Nerve  Centres,"    "The    Reflex    Consequences  of  Ovarian    Irritation,"    "When  Not  to  Give 
Iron,"  "Artificial  Digestion,"  etc.,  thus  presenting  n  complete  reflex  of  the  existing  condition 
of  therapeutical  science. 
TOY  THE  SAME  AUTHOR. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS*,  AND  WHAT 

IT  TEACHES.    Being  the  Fothergillinn  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
12mo.  of  156  pages;  cloth,  $1  00.     {Just  Ready.) 

\UOODBURY  {FRANK),  M.D., 

'  '  Physician  to  the  German  Hospital,  Philadelphia,  late  Chief  Assist,  to  Med.  Clinic,  Jeff.  College 

Hospital,  etc. 

A    HANDBOOK   OF   THE   PRINCIPLES  AND   PRACTICE   OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.     Based  upon  Husband's  Handbook 
of  Practice.     In  one  neat  volume,  royal  12mo.     (Preparing.) 

LJABERSHON  (S.  O.).  M.D. 

■*■-*-  Senior  Physician  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Guy's 

Hospital,  etc 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Cnnal,  (Esophagus,  Caecum,  Intes- 
tines, and  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.     (Now  Ready.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Practice  of  Medicine).    17 
REYNOLDS  (J.  RVSSELL),  M.D.,  -     . 

-*•*'         Pro/.  11/ the  Principles  and  Practice  of  Medicine  in  Univ.  College,  London. 

A  SYSTEM  OP  MKPKMNE   with  Notks  and  Additions  by  Hknry  Habts- 
horne,  M.D.,  late  Professor  of  Hygiene  in  the  University  of  Penna.     In  three  large  and 
handsome  octavo  volumes,  containing  3052  closely  printed  douhle-columned  pages,  with 
numerous  illustrations.     Sold  only  by  subscription.     Price  per  vol.,  in  cloth,  $5.00;   in 
sheep,  $6.00:  half  Russia,  raised  bands,  $6.50.     Per  set  in  cloth,  $15;  sheep,  $18;  half 
Russia,  $19.50 
Volume  I.   (just  ready)  contains  General  Diseases  and  Diseases  op  the  Nervous  System. 
Volume  II.    (just  ready)  contains  Diseases  of  Respiratory  and  Circulatory  Systems. 
Volume    III.    (just  ready)    contains    Diseases  op   the  Digestive  and  Blood. Glandular 
Systems,  op  the  Urinary  Organs,  of  the  Female  Reproductive  System,  and  of  the 
Cutaneous  System. 
Reynolds's  System  of  Medicine,  recently  completed,  has  acquired,  since  the  first  appearance 
of  the  first  volume,  the  well-deserved  reputation  of  being  the  work  in  which  modern   British 
medicine  is  presented  in  its  fullest  and  most  practical  form.     This  could  scarce  be  otherwise  in 
view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  leading  minds  of  the  profession, 
each  subject  being  treated  by  some  gentleman  who  is  regarded  as  its  highest  authority — as  for 
instance,  Diseases  of  the  Bladder  by  Sir  Henry  Thompson,   Malpositions  of  the  Uterus  by 
Graily  Hewitt,  Insanity  by  Henry  Maudsley,  Consumption  by  J.  Hughes  Bennet,  Dis- 
eases of  the  Spine  by  Charges  Bland  Radcliffe,  Pericarditis  by  Francis  Sibson,  Alcoholism 
by  Francis  E.  Anstie,  Renal  Affections  by  William  Roberts,   Asthma  by  Hyde   Salter, 
Cerebral  Affections  by  tl    Charlton  Bastian,  Gout  and  Rheumatism  by  Alfred  Baring  Gab- 
rod,  Constitutional  Syphilis  by  Jonathan  Hutchinson,  Diseases  of  the  Stomach  by  Wilson 
Fox,  Diseases  of  the  Skin  by  Balmanno  Squire,   Affections  of  the  Larynx  by  Morell  Mac- 
benzie,  Diseases  of  the  Rectum  by  Blizard  Curling,   Diabetes  by  Lauder  Brunton,  Intes- 
tinal Diseases  by  John  Syer  Bristowe,  Catalepsy  and  Somnambulism  by  Thomas  King  Cham- 
bers, Apoplexy  by  J.  Hughlings  Jackson,  Angina  Pectoris  by  Professor  Gairdner,  Emphy- 
sema of  the  Lungs  by  Sir  William  Jenner,  etc.  etc.     All  the  leading  schools  in  Great  Britain 
have  contributed  their  best  men  in  generous  rivalry,  to  build  up  this  monument  of  medical  sci- 
ence.    St.  Bartholomew's,  Guy's,  St  Thomas's,  University  College,  St  Mary's  in  London,  while 
the  Edinburgh,  Glasgow,  and  Manchester  schools  are  equally  well  represented,  the  Army  Medical 
School  at  Netley,  the  military  and  naval  services,  and  the  public  health  boards.     That  a  work 
conceived  in  such  a  spirit,  and  carried  out  under  such  auspices  should  prove  an  indispensable 
treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was  inevitable,  and 
the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which  it  has  acquired  on  this 
side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the  two  preeminently  practical  nations. 
Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in  this 
country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which  shall  ren- 
der it  accessible  to  all.     To  meet  this  demand  the  present  edition  has  been  undertaken.     The 
five  volumes  and  five  thousand  pages  of  the  original  have   by  the  use  of  a  smaller  type  and  double 
columns,  been  compressed  into  three  volumes  of  over  three  thousand  pages,  clearly  and  hand- 
somely printed,  and  offered  at  a  price  which  renders  it  one  of  the  cheapest  works  ever  presented 
to  the  American  profession. 

But  not  only  is  the  American  edition  more  convenient  and  lower  priced  than  the  English; 
it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance  of  a 
portion  of  the  work,  additions  are  required  to  bring  up  the  subjects  to  the  existing  condition 
of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England,  require  more 
elaborate  treatment  to  adapt  the  articles  devoted  to  tbem  to  the  want*  of  the  American  physi- 
cian ;  and  there  are  points  on  which  the  received  practice  in  this  country  differs  from  that 
adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken  by  Henry  Harts - 
horne,  M.D.,late  Professor  of  Hygiene  in  the  University  of  Pennsylvania,  who  has  endeavored 
to  render  the  work  fully  up  to  the  day,  and  as  useful  to  the  American  physician  as  it  has  proved 
to  be  to  his  English  brethren.  The  number  of  illustrations  has  also  been  largely  increased,  and 
no  effort  spared  to  render  the  typographical  execution  unexceptionable  in  every  respect. 


Really  too  much  praise  can  scarcely  be  given  to 
this  noble  book.  It  is  a  cyclopsedia  of  medicine 
written  by  some  of  the  best  men  of  Europe.  It  is 
full  of  useful  information  such  as  one  finds  frequent 
need  of  in  one's  dally  work  As  a  book  of  reference 
it  is  invaluable.  It  is  up  with  the  times.  It  is  clear 
and  concentrated  in  style,  and  its  form  is  worthy 
of  its  famous  publisher.  —  Louisville  Mtd.  flews, 
Jan.  31,  1880. 

"Reynolds'  System  of  Medicine"  is  justly  con- 
sidered the  most  popular  work  on  the  principles  and 
practice  of  medicine  in  the  English  language.  The 
contributors  to  this  work  are  gentlemen  of  well- 
known   reputation   on   both   sides   of  the   Atlantic. 


subjects  with  which  he  should  be  familiar. — Oail- 
lard's  Med.  Journ.,  Feb.  1880. 

There  is  no  medical  work  which  we  have  in  times 
past  more  frequently  and  fully  consulted  when  per- 
plexed by  doubts  as  to  treatment,  or  by  having  un- 
usual or  apparently  inexplicable  symptoms  pre- 
sented to  us  than  "Reynolds'  System  of  Medicine." 
Among  its  contributors  are  gentlemen  who  are  as 
well  known  by  reputation  upon  this  side  of  the 
Atlantic  as  in  Great  Britain,  and  whose  right  to 
speak  with  anthority  upon  the  subjects  about 
which  they  have  written,  is  recognized  the  world 
over.  They  have  evidently  striven  to  make  their 
essays  as  practical  as  possible,  and  while  these  are 


Each  gentleman  has  striven  to  make  his  part  of  the  i  sufficiently  full  to  entitle  them  to  the  name  of 
work  as  practical  as  possible,  and  the  information  ;  monographs,  they  are  not  loaded  down  with  such 
contained  is  such  as  is  needed  by  the  busy  practi-  [  an  amount  of  detail  as  to  render  them  wearisome 
tioner.  —  St.  Louis  Med.  and  Surg.  Journ. ,  Jan.  '80.  I  to  the  general  reader.     In  a  word,  they  contain  just 

|  that  kind  of  information  which  the  busy  practitioner 
Dr.  Hartshorne  has  made  ample  additions  and  frequently  finds  himself  in  need  of.  In  order  that 
revisions,  all  of  which  give  increased  value  to  the  I  any  deficiencies  may  be  supplied,  Ihe  publishers 
volume,  and  render  it  more  useful  to  the  Ameri-  '  have  committed  the  preparation  of  the  book  for  the 
can  practitioner.  There  is  no  volume  in  English  press  to  Dr.  Henry  Hartshorne,  whose  judicious 
medical  literature  more  valuable,  and  every  pur-  '  notes  distributed  throughout  the  volume  afford  abun- 
chaser  will,  on  becoming  familiar  with  it,  cougrat-  I  dant  evidence  of  the  thoroughness  of  the  revision  to 
nlate  himself  on  the  possession  of  this  va»t  store-  i  which  he  has  subjected  it. — Am.  Jour. Mtd.  Sciences, 
house  of  information,  in  regard  to  so  many  of  the  [  Jan.  1880. 


18     Henry  C.  Lea's  Son  &  Co.'s  Publications — (Prac  of  Med.,  &c). 


f>ARTHOLOW  (ROBERTS).  A.M.,  M.D..  LL.D. 

■*-'  Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jeff  Med.  Coll.  of  Phila  ,  etc. 

A  PRACTICAL  TREATISE  OX  ELECTRICITY  IX  ITS  APPLI- 
CATION TO  MEDICINE.  In  one  very  handsome  octavo  volume  of  about  450  pages, 
with  illustrations.     (In  press.) 

The  constantly  increasing  therapeutic  use  of  electricity,  and  the  absence  of  a  concise  guide 
suited  to  the  wants  of  the  general  practitioner,  have  induced  the  author  to  prepare  the  present 
volume.  His  object  has  been  to  present  the  most  advanced  state  of  existing  knowledge  in  a 
form  divested  of  unnecessary  technicalities,  keeping  constantly  in  view  the  practical  needs  of 
the  student  and  physician. 

As  the  volume  is  founded  upon  a  course  of  lectures  delivered  in  the  Jefferson  Medical  College 
during  the  spring  of  1880,  its  adaptation  to  its  purpose  is  insured.  Dr.  Bartholow's  power  of  lucid 
exposition  is  well  known,  and  is  particularly  desirable  in  a  subject  such  as  this,  treated  from 
the  standpoint  of  the  general  practitioner  and-  not  of  the  specialist. 

PINLAFSON  (JAMES),  M.D., 

•*-  Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

CLIXICAL  DIAGXOSIS;  A  Handbook  for  Students  and  Prac- 
titioners of  Medicine.  In  one  handsome  12mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.     (Just  Issued.) 

The  book  is  an  excellent  one,  clear,  concise,  conve- 
nient, practical.  It  is  replete  with  the  very  know- 
ledge the  student  needs  when  he  qoits  the  lecture- 
room  and  the  laboratory  for  the  ward  and  sick-room, 
and  does  not  lack  in  information  that  will  meet  the 
wants  of  experienced  and  older  men. — Phila.  Med. 
Times,  Jan.  4,  1879. 


This  io  one  of  the  really  useful  books.    It  is  attrac- 


tive from  preface  to  the  final  page,  and  ought  to  be 
gi  ven  a  place  on  every  office  table,  because  it  contains 
in  a  condensed  form  all  that  is  valuable  in  semeiology 
and  diagnostics  to  be  found  in  bulkier  volumes,  and 
because  in  its  arrangement  and  complete  index,  it  is 
unusually  convenient  for  quick  reference  in  any 
emergency  that  may  come  upon  thebnsy  practitioner. 
—N.  C.  Med.  Journ.,  Jan.  1879. 


TJAM1LTOS. (ALLAN  Mr  LANE),  M.D., 

■*■-*-  Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.7., 

and  at  the  Oat-  Patients'  Department  of  the  New  York  Hospital. 

NERYOUSDISEASES;THEIRDESCRIPTIOXAXD  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illus. ;  cloth,  $3  50.     (Just  Issued.) 
flHARCOT  (J.  M.). 

v         Prrfessor  to  the  Faculty  of  Med.  Paris,  Phys.  to  La  Salpetriire,  etc. 

LECTURES  OX  DISEASES  OP  THE  NERVOUS  SYSTEM.   Trans- 

lated  from  the  Second  Edition  by  George  Sigbrson,  M.D..  M.Ch.,  Lecturer  on  Biology, 
et«.,  Cath.  Univ.  of  Ireland.  With  illustrations.  1  vol.  8vo.  of  288  pages.  Cloth,  $1  75. 
(Just  Ready.) 

CLfXiriAL    OBSERVATIONS  ON   FUNCTIONAL  I      ond  America  r  Edition     In  onehandsome  octavo 
NERVOUS  DISORDERS   BvC.  Ha.vopiei.d  Jokes.        volumeof  348  pagei»,cloth,  *3  25. 
M.D.,  f  hysiciau  to  St.  Mary's  Hospital,  &c.  Sec-  | 


MORRIS  (MALCOLM).  M.D., 

•*■'■*-  Joint  Lecturer  on  Dermatology,  St.  Mary's  Hospital  Med.  School. 

SKIN  DISEASES,  I  Deluding  their  Definitions,  Symptoms,  Diagnosis, 

Prognofis,  Morbid  Anatomy,  and  Treatment.    A  Manual  for  Students  and  Practitioners. 
In  one  12mo.  volume  of  over  300  pages.    With  illustrations.    Cloth,  $1  75.     (Now  Ready.) 

To  physicians  who  would  like  to  know  something  appliances  of  cutaneous  medicine.  He  has  produced 
about  skin  disease*,  so  that  when  a  patient  presents  a  plain,  practical  book,  by  aid  of  which,  who  so 
himself  for  relief  they  can  make  a  correct  diagnosis  chooses  may  trtin  his  eye  to  the  recognition  of 
and  prescribe  a  rational  treatment,  we  unhesitatingly  light  but  significant  differences.  The  descriptions 
recommend  this  little  book  of  Dr.  Morris.  The  affec-  are  neither  too  vaeue  nor  over-refined:  the  direc- 
tions of  the  skin  are  described  in  a  terse,  lncid  man-  tions  for  treatment  are  clear  and  succinct. — London 
ner.  and  their  several  characteristics  ho  plainly  set  Brain,  April,  1880 

forth  that  diagnosis  will  be   easy.     The   treatment  The  aathor  has  handled  his  subject  in  a  clear  and 

in  each  case  is  such  as  the  experience  of  the  most  eonciKe  mi4Iloeri  and  a8  ft  text-book  to  student*  his 

eminent  dermatologist*  advise.— Cincinnati  M^di-  manuaI  wU1  be  roand  nseful.—Jfedfca*  and  Surgi- 

cal  News,  Apiil,  1880.  ca1  Rep.tr,ert  March  27,  1S80. 

This  is  emphatically  a  learner's  book  ;  for  we  can  The>  author's  task  has  be?n  well  done  and  has  pro- 

ssfely  say,  so  far  as  our  judgment  goes,  that  in  the  dnced  one  of  the  best  recent  works  upon  the  difficult 

whole  range  of  medical  literature  of  a  like  scope,  subject  of  which  It  feats;  thereis  no  work  published 

there  is  no  hook  which  for  clearness  of  expression  which  gives  a  better  view  of  the  elementary  facts 

and    methodical   arrangement  it   better  adapted  to  and  oriiciples  of  dermatology. — New  Orleans  Medi- 

promote  a   rational   conception   of  dermatology,   a  cal  and  Surgical  Journal,  April,  1880. 

branch  confessedly  difflcnlt   and  perplexing   to  the  Thu  excftltent  little  book  is   the   first  work  of  a 

Wnner.-St.    Louis  Courier  of  Medicine,  April,  distinguished  puoil  of  Jonathan  Hntchlnson;  it  re- 

™8i).  commends  itself  above  all  by  its  clearness,  method. 

The  author  of  this  manual  hss  evidently  a  full  and  nn1  precision — Pa-is  Annates  de  Dtrmatologie  et 

iotimate  acquaintance  with  the  literature  of  derma-  de  Syphiligraphie,  25  April,  18S0. 
tology,  and  with  the  most  recent  developments  and 


F 


OX  (TILBURT).  M.D..F.R.C.P.,nvd  T.  C.  FOX.  B.A.,  M.R.C.S., 

phyafcl"n  to  the  Department  for  Skin  Diseases,  Vnivfrsitf/  College  Hosjiitol. 

EPITOME  OF  SKIX  DISEASES.     WITH  FORMULAE.     For  Stu- 

dents  and  Practitionkr8.    Second  edition, thoroughly  revised  and  greatly  enlarged.   In 
one  very  handsome  12mo.  volume  of  216  pages.     Cloth,  $1  38.     (Just  Issued.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dia.ofthe  Chest, (he).   19 


PLINT  (A  USTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  N.  Y. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism. 

Second  edition.     In  one  handsome  royal  12mo.  volume:  cloth,  $1  63.     (Just  Ready.) 

Prof.  Flint  Is  so  well  known  us  a  medical  teacher  (  physician's   library.  —  Med.   and    Surg.    Reporter, 

and  writer  that  it  seems   superfluous   to  state  that    March  IS.  1S80. 


the  subject  has  been  treated  in  a  thorough  and  sys- 
tematic mauuer.  In  revising  It  for  a  second  edition 
the  author  has  confined  himself  to  such  additions  as 
seem  likely  to  render  it  more  useful,  not  only  to 
students  engag»d  In  the  practical  study  of  the  sub- 


The  little  work  before  us  has  already  become  a 
standard  one,  and  has  become  exleu*ively  adopted 
as  a  text-book.  There  is  certainly  none  better.  It 
contains  the  substance  of  the  lessons  which  the 
author  has  for  nnny  years  given,  in  connection  with 


ject,  but  also  to  practitioners  as  a  handbook  for  prac,icai  instruction  in  auscultation  and  percussion, 
ready  reference,  and  we  do  not  hesitate  in  saying  t0  prjTate  classes,  composed  of  medical  students  and 
that  it  would  prove  a  valuable  addition  to   every  |  petitioners.  —  Cincinnati  Med.  News,  Feb.  1S80. 

DT   THE  SAME   AUTHOR. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS;  in  a  series  of  Clinical  Studies.  By  Austin 
Flint,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.     In  one  handsome  octavo  volume  :  $3  50.     (Lately  Issued.) 


T>  Y  THE  SA  ME  A  UTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 

Dr.  Flint  chose  a  difficult  subject  for  his  researches,  \  *nd  clearest  practical  treatise  on  those  subjects,  and 
and  has  shown  remarkable  powers  of  observation  ,  should  be  in  the  hands  of  all  practitioners  and  Stu- 
art d  reflection,  as  well  as  great  industry,  in  his  treat-  |  ients.  It  is  a  credit  to  American  medical  literature, 
ment  of  it.   His  book  must  be  considered  the  fullest  I  —  Amer.  Journ.  of  the  Med.  Sciences,  July,  1S60. 

TOY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 


B 


ROWN  {LENNOX),  F.R.G.S.  Ed., 

Senior  Surgeon  to  the  Central  London  Throat  and  Ear  Hospital,  etc. 

THE  THROAT  AND  ITS  DISEASES.     With  one  hundred  Typical 

Illustrations  in  colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author. 
In  one  very  handsome  imperial  octavo  volume  of  351  pages  ;  cloth,  $5  00.    (Just  Ready.) 


VE1LER  (CARL),  M.D., 

^J  Lecturer  on  Laryngoscopy  at  the  Univ.  of  Penna.,   Chief  of  the  Throat  Dispensary  at  the 

Univ.  Hospital,  Phila.,  etc. 

HANDBOOK  OP  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 

THE    THROAT   AND    NASAL   CAVITIES.      In   one  handsome  royal  12mo.  volume, 

of  156  pages,  with  35  illustrations;  cloth,  $1.      (Just  Ready.) 

We  most  heartily  commend  this  book  as  showing        A  convenient  little  handbook,  clear,  concise,  and 

6ound  judgment  in  practice,  and  perfect  faniiliari'y    accurate  in  its  method,  and  admirably  fulfilling  its 

with   the  literature  of  tlie  specialty  it  so  ably  epi-     purpose  of  bringing  the  subject  of  which  it  treats 

tuinizes. —  Philada.   Med.  Times,  July  5,  1879.  within   the   comprehension   of  the  general  practi- 

I  tioner. — N.  C.  Med.  Jour.,  June,  1879. 


WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  With  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
350  pages;  cloth,  $2  50. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.  In  one  neatroyal  12mo.  volume,  cloth, 
$1  25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  Edition.  In 
1  vol.  8vo.,  420  pp.,  cloth,  $3  00. 

CHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  In  one  handsome 
octavo  volume.     Cloth,  $2  75. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.8vo.,  cloth. 
of  500  pages      Price,  $3  00. 

WH.SON  S  STUDENT'S  BOOK  OF  CUTANEOUS 
MEDICINE  and  Diseases  op  the  Skin.  In  one 
very  handsome  royal  12mo   volume.    $3  50. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  ocatvo 
volume  of  about  500  pages  :  cloth,  $3  50. 

SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MEDIABLE STAGES.    1  vol.8vo.,pp.254.   $2  25. 

BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions. In  onel2mo.  vol   of  301  pages,  cloth,  $2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
Hudson,  M.D.,  M.R.I. A.,  Physician  to  the  Meath 
Hospital.     In  one  vol.  8vo.,  cloth,  $2  50. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.C  C.  In  one  octavo  volume  of  362  pages,  cloth 
*2  25. 

HILLIER'S  HANDBOOK  OF  SKIN  DISEASES,  for 
Students  and   Practitioners.     Second  Am    Ed.      In 

'  one  royal  12mo.  vol.  of  358  pp.  With  illustrations. 
Cloth,  $2  25. 


20    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Venereal Diseases, Sc.) 
f>UMSTEAD  {FREEMAN  J.),  M.D.,LL.D., 

•*-"         Professor  of  Venereal  Diseases  at  the  Col.  of  Phys.  and  Snrg.,  New  York,  Ac. 

THE  PATHOLOGY  AND   TREATMENT  OF  VENEREAL  DIS- 

EASES.    Including  the  results  of  recent  investigations  upon  the  subject.    Fourth  edition, 
revised   and  larg»ly  rewritten  with  the  co-operation  of  R.  W.  Taylor,  M.D.,  of  New 
York,   Prof,  of  Dermatology  in   the  Univ.  of  Vt.      In  one  large   and  handsome  octavo 
volume  of  835  pages,  with  138  illustrations.     Cloth,  $4  75  ;    leather,  $5  75 ;    half  Russia, 
$6  25.      (Just  Ready.) 
This  work,  on  its  first  appearance,  immediately  took  the  position  of  a  standard  authority  on 
ks  subject  wherever  the  language  is  spoken,  and  the  success  of  nn  Italian  translation  shows 
that  it  is  regarded  with  equal  favor  on  the  Continent  of  Europe.  In  repeated  editions  the  author 
labored  sedulously  to  render  it  more  worthy  of  its  reputation,  and  in  the  present  revision  no 
pains    have    been  spared  to  perfect  it  as  far  as  possible.     Several  years  having  elapsed  since 
the  publication  of  the  third  edition,  much  material  has  been  accumulated  during  the  interval 
by  the  industry  of  sypbilologi>ts,  and  new  views  have   been  enunciated.     All   this    so  far  as 
confirmed  by  observation  and  experience,  has  been  incorporated;    many  portions  of  the  volume 
been  rewritten,  the  series  of  illustrations  has  been  enlarged  and  improved,  and  the  whole  may 
be  regarded  rather  as  anew  work  than  as  a  new  edition.    It  is  confidently  presented  as  fully  on 
a  level  with  the  most  advanced  condition  of  syphilology,  and  as  a  work  to  which  the  practi- 
tioner may  refer  with  the  certainty  of  finding  clearly  and  succinctly  set  forth  whatever  falls 
within  the  scope  of  such  a  treatise. 

will  more  than  repay  him  for  the  outlay.— Archives 
of  Medicine,  April,  18«0. 

This  now  classical  work  on  venereal  disease  comes 


We  have  to  congratulate  our  countrymen  upon 
the  truly  valuable  addition  which  they  have  made 
to  American  literature.  The  careful  estimate  of  the 
value  of  the  volume,  which  we  have  made,  justifies 


to  us  In  its  fourth  edition  rewritten,  enlarged,  and 


us  in  declaring  that  tins  is  the  best  treatise  on  |  materially  improved  in  every  way.  Dr.  Tavlor,  us 
venereal  diseases  Id  the  English  langoage,  and,  we  ■  we  had  eTery  reason  t0  expect  hag  performed  this 
might  add,  if  there  is  a  better  in  any  other  tongue  I  par,  of  hig  work  with  unasual  excellence.  We  feel 
we  cannot  name  it ;  there  are  certainly  no  books  in  i  that  what  hag  Deen  wriUen  has  done  bnt  scantv  jus- 
which  the  student  or  the  general   practitioner  can  I  tice  to  the  merUg  of  thig  trnl  t  treatige'.-St. 

find  such  an  excellent  risumi  of  the  literature  of  ,  houU  Courier  of  Medicine,  Feb.  1830 
any  topic,  and  snch  practical  suggestions  regarding        _-.,..         ,  ,  ...  . 

the  treatment  of  the  various  complications  of  every  ™*?ld  that  we  haTe  here  practically  a  new  book 
venereal  disease.  We  take  pleasure  in  repeating  !  T^A'u6  8'aten,ent  of  tbe  title-page,  as  to  t he  fact 
that  we  believe  this  to  be  the  best  treatise  on  vene-  I  *"»*  "  hag  beea  largely  rewritten,  is  a  sufficiently 
real  disease  in  the  Ejgllah  language,  and  we  con-  i  modest  announcement  for  th*  Important  changes  in 
gratulate  the  authors  upon  their  brilliant  addition  !  th«  ***!■•  After  a  thorough  examination  of  tbe  pre- 
to  American  medical  llterature.-C/iicaoo  Med.  Jour.  I  seDt  edition,  we  cau  assert  confidently  that  the  enor- 
nal  and  Examiner,  February,  1880.  mon»  labor  wf  haTe  described  has  been  here  most 

.  faithfully  and    conscientiously    performed. — Amer. 

It  is,  without  exception,  the  most  valuable  single     journ.  Med.  Sci.,  Jan.  1880. 
work  on  all  branches  of  the  subject  of  which  it  treats 

in  any  language.  The  pathology  Is  sound,  the  work  ,,"  u  one  of  the  best  general  treatises  on  venereal 
is,  at  the  same  time,  in  the  highest  degree  practical,  diseases  with  which  we  are  acquainted  and  is  espe- 
and  the  hints  that  be  will  get  from  it  for  the  man-  cially  '°  be  recommended  as  a  guide  to  the  treatment 
agemeut  of  any  one  case,  at  all  obscure  or  obstinate,  |  of  syphilis.— iondon  Practitioner,  March,  1S80. 

(1ULLERIER  {A.),  and         ~DUMSTEAD  (FREEMAN  J.), 

*•/        Surgeon  to  the  Hdpitaldu  Midi.  ■*-*       Professor  of Venereal  Diseases  in  the  College  oj 

Physicians  find  Surgeons.  AT.  T 

AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  hy 

Freeman. I.  Biimbtead.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  tbem  the  size  of 
life;  strongly  bound  in  cloth.  $17  00  ;  also,  in  five  parts,  stout  wrappers,  a*  $?  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 
practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 

LEES    LECTFRES     ON     SYPIIIL'S    AND    SOME  |  HILL    ON    SYPHILIS  AND    LOCAL   CONTAGIOUS 
FORMS  OF  LOCAL  DISEASE  AKFEUTIXG  I'RIN-  !      DISORDERS.     In  one  handsome  octavo  volume; 
CII'ALLY  THE  ORGANS  OF  GENERATION.     In  j      cloth    #3  2o. 
one  handsome  octavo  volume;  cloth,  %l  21. 


WEST  (CHARLES),  U.D., 

Physicianto  the  Hospital  for  Sink  Children,  London,  tc. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILD- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50;  leather,  $5  50.  (Irately  Issued.) 

T>Y  THE  SAME  AUTHOR.    (  Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered   at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.     In  one  volume   small  12mo.,  cloth,  $1  00. 

T>  Y  THE  SA  MB  A  UTHOB. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  650  pages,  clot) , 
$3  75;  leather,  $4  76. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Children,  tic).   21 


JgMITH  {J.  LEWIS),  M.D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Med.  College,  F  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  Edition,  revised  and  enlarged.     In  one  handsome  octavo  volume 
o    about  750  pages,  with  illustrations.     Cloth,  $4  50;  leather,  $5  50;  half  Russia,  $6. 
(Now  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  the. English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  respect  of  a  continuance  of  professional 
confidence.     Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materially 
increased. 

b  tb  American  and  foreign,  eipecially  those  bearing 
on  therapeutics.  Altogether  the  book  has  been 
greatly  improved,  while  it  has  not  been  greatly 
increased  In  size.  —  Aew  York  Medical  Journal, 
June,  1S79. 

This  excellent  work  is  so  well  known  tbat  an 
ex  ended  notice  at  this  time  wonld  be  superfluous. 
The  author  has  taken  advantage  of  the  demand  for 


In  the  period  which  has  elapsed  since  the  third 
edition  of  the  work,  so  extensive  have  been  the  ad- 
vances that  whole  chapters  required  to  be  rewritten, 
and  hardly  a  page  could  pass  without  some  material 
correction  or  addition.  This  labor  has  occupied  the 
writer  closely,  and  he  has  performed  it  conscien- 
tiously, so  that  the  book  may  be  considered  a  faith- 
ful portraiture  of  an  exceptionally  wide  clinical 
experience  in  infantile  diseases,  corrected  by  a  care-  j  another"  new"  edff  on  to  7evTse~in  a  most  careful 


ful  study  of  the  recent  literature  of  the  subject 
Med.  and  Surg.  Reporter,  April  5,  1879. 

It  is  scarcely  necessary  for  us  to  say  the  work  be- 
fore us  is  a  standard  work  upon  diseases  of  children, 
and  that  no  work  has  a  higher  standing  than  it  upon 
those  affections.     In  consequence  of  its  thorough  re- 


manner  the  entire  book  ;  and  the  numerous  correc- 
tions and  additions  evince  a  determination  on  his 
part  to  keep  fully  abreast  with  the  rapid  progress 
that  Is  being  made  in  the  knowledge  and  treatment 
of  children's  diseases.  By  the  adoption  of  a  some- 
what cloNer  type,  an  increase  in  size  of  only  thirty 


vision,  the  work  has  been  made  of  more  value  than  pages  has  been  necessitated  by  the  new  subject 
ever,  and  may  be  regarded  as  fully  abreast  of  the  |  matter  introduced.—  Boston  Mad.  and  Surg.  Jour., 
times.     We  cordially  commend  it  to   students  and  i  May  29,  1879. 

physicians.  There  is  no  better  work  in  the  language  |  Probably  no  other  work  ever  published  in  this 
on   diseases  of  children.— Cincinnati  Med.  News,  |countrv  upon  a  medical  subject  has  reached  such  a 


March,  1879. 


|  heighth  of  popularity  as  has  this  well-known  trea- 


The  author  has  evidently  determined  that  it  shall  I  tise.     As  a  text  and  reference-book  it  is  pre-emi 


not  lose  ground  in  the  esteem  of  the  profession  for 
want  of  the  latest  knowledge  on  that  important 
department  of  medicine.  He  has  accordingly  in- 
corporated in  the  present  edition  the  useful  and 
practical  results  of  the  latest  study  and  experience, 


nently  the  authority  upon  diseases  of  children.  It 
stands  deservedly  higher  in  the  estimation  of  the 
profession  than  any  other  work  upon  the  same  sub- 
ject.— Nashviltt  Journ.  of  Med.  and  Surg.,  Hay, 
1879. 


g WAYNE  {JOSEPH  GRIFFITHS),  M.D., 

Physician-Accoucheur  to  the  British  General  Hospital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE      Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.D.  With  Illustrations.   In  one 
neat  12mo.  volume.     Cloth,  $1  25.     (Lately  Issued.) 
***  See  p.  3  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  "  American  Journal  op  the  Medical  Sciences." 

CHURCHILL   ON  THE  PUERPERAL  FEVER  AND  I 
OTHER  DISEASESPECOLIARTO  WOMEN,  lvol. 
8vo.,  pp.  450,  cloth.    $2  SO. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES.  With  illustrations.    Eleventh  Edition.  I 
with  the  Author's  lastimprovementsand  correc-  | 
tions.    In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    $3  00. 


MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  1  vol.  Svo.,  pp. 
365.  cloth.    $2  00. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vol. 
8vo.,'  pp   528,  cloth.    $3  50. 


H 


a 


ODGE  {HUGH  L.),  M.D., 

Emeritus  Professor  of  Obstetrics,  Ac,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacements 

of  the  Uterus.  With  original  illustrations.  Second  edition,  revised  and  enlarged.  In 
one  beautifully  printed  octavo  volume  of  581  pages,  cloth,  $4  50. 

HURCHILL  {FLEETWOOD),  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additions 
by  D.  Francis  Condie,  M.D.,  author  of  a  "  Practioal  Treatise  on  the  Diseases  of  Chil- 
dren," Ac.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $5  00. 

MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS  i  RIOBT'S  SYSTEM  OF  MIDWIFERY.  With  notes 
AND  SYMPTOMS  OF  PREGNANCY.  With  two  j  and  Additional  Illustrations.  Second  American 
exquisitecolored  plates,  and  numerous  wood-cuts  .|  edition.  One  volume  octavo,  cloth  422  P«8es, 
To  1  vol.  8vo..ofnearlv«Ont>p..  cloth.  *3  7«.  \       *2  SO. 

CONDTE'S  PRACTICAL  TREATISE  ON  THE  DIS-  '  SMITH'S  PRACTICAL  TREATISE  ON  THE  WAST- 
EASES  OF  CHILDREN.  Sixth  edition,  revised,  ING  DISEASES  OF  INFANCY  AND  CH.LDHiCD. 
and  augmented.  In  one  large  octavo  volume  ol  j  Second  American,  from  the  second  revised  and 
nearly  8<"0  closely-printed  pages,  cloth,  $5  25;;  enlarged  Entlish  edition.  In  one  handsome  oeta- 
leather.  $6  25.  I      vo  volume,  cloth ,  $2  50. 


22      Henry  C.  Lea's  Son  &  Co.'s  Publications — (Dis.  of  Women). 


rTHOMAS  {T.GAILLARD),M.D., 

*  Professor  of  Obstetric*.  Ac. .  in  the  College  of  Physician*  and  Surgeons,  N.  T.,*c 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Fifth 

edition,  thoroughly  revised  and  rewritten.     In  one  large  and  handsome  octavo  volume 
of  over  850  pages,  with  about  270  illustrations.      (In  Press.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  a  new  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has 
been  received.  Every  portion  of  the  work  has  been  carefully  revised,  very  much  of  it  has 
been  rewritten,  and  additions  and  alterations  introduced  wherever  the  advance  of  science  and 
the  increased  experience  of  the  author  have  shown  them  desirable.  At  the  same  time  special 
care  has  been  exercised  to  avoid  undue  increase  in  the  size  of  the  volume.  To  accommodate 
the  numerous  additions  a  more  condensed  but  vt  ry  clear  letter  has  been  used,  notwithstanding 
which,  the  number  of  pages  has  been  increased  by  more  than  fifty.  The  series  of  illustrations 
has  been  extensively  changed  ;  many  which  seemed  to  be  superfluous  have  been  omitted,  and  a 
large  number  of  new  and  superior  drawings  have  been  inserted.  In  its  improved  form,  there- 
fore, it  is  hoped  that  the  volume  will  maintain  the  character  it  has  acquired  of  a  standard 
authority  on  every  detail  of  its  important  subject. 

A  few  notices  of  the  previous  edition  are  appended. 

A  work  which  has  reached  a  fourth  edition,  and  i  in?  light  and  instruction.  Dr.  Thomas  Is  a  man  with  a 
that.  too.  in  the  short  space  of  five  years,  has  achieved  very  clear  head  and  decided  views,  and  there  seems  to 
a  reputation  which  places  it  almost  beyond  the  reach  \  be  nothing  which  he  so  much  dislikes  as  hazy  notions 
of  criticism,  and  the  favorableopinions  which  we  have  I  if  diagnosis  and  blind  routine  and  unreasonable  thera- 
already  expressed  of  the  former  editions  seem  to  re-  peutics.  The  student  who  will  thoroughly  study  this 
quire  that  we  should  do  little  more  than  announce  book  and  test  its  principles  by  clinical  observation,  will 
this  new  issue.  We  cannot  refrain  from  saying  that,  :ertainly  not  be  guilty  of  thesefaults. — London  Lancet, 
as  a  practical  work,  this  is  second  to  none  in  the  Kng-  Peb.  13.  1875 
lish.  or.  indeed,  in  any  other  language     The  arrange-        Beluctantly  we  are  obliged  to  close  this  nnsatis- 


desired  by  the  practitioner  who  wants  a  thoroughly  J  ,aken  ,he  lead  far  ahead  of  his  eonfrireit,  and  as  an 
elinical  work,  one  to  which  he  can  refer  in  difficult  ,athor  he  certainly  ha(t  met  with  unusual  and  roer- 
cases  of  doubttul  diagnosis  with  the  certaintj  of  gam-  |  Ued  SUCces8.-^m.  .Town,  of  Obstetrics,  Nov.  1874. 


BARNES  (ROBERT).  M.D.,  F.R.C.P., 

-*-"'  Obstetric  Ph.ysic.iov  to  St.  Thomas'*  Hospital,  A-c. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL diseases  of  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.     In  one  Handsome  octavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  *4  50;  leather,  $5  50  ;  half  Russia,  $6.     (Just  Ready.) 
The  call  for  a  new  edition  of  Dr.  Barnes's  work  on  the  Diseases  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profession  than  before.     By  a  rear- 
rangement and  careful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gynaecological 
Relations  of  the  Bladder  an  i   Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introduced  where  experience  has  shown  them  to  be  needed.    It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynaecological  science. 

Dr  Barnes  stands  at  the  bead  of  his  profession  In  the  work  is  a  valuable  one,  and  should  be  largely 
the  old  conntry,  and  It  requires  but  scant  scrutiny  consulted  by  the  profession. — Am.  St'pp  Obstetrical 
of  his  book  to  show  that  it  has  been  sketched  by  a  Journ.  Ot.  Britain  and  Ireland,  Oct.  1878. 
master.  It  is  plain,  practical  common  sense  ;  shows  |  No  other  gTIuecolog1cal  work  holdH  a  higher  posi. 
very  deep  research  without  being  pedantic;  is  emi-  ,  Mon  to*\ng  \**omi  an  authority  everywhere  in 
nently  calculated  to  inspire  enthusiasm  without  in-  dlM,a8e(t  0f  women.  The  work  has  been  brought 
cheating  rashness;  points  out  the  dangers  to  be  fnlly  abrea8t  of  pregeDt  knowledge.  Every  practl- 
avoided  as  well  as  the  success  to  be  achieved  in  the  tioner  of  raedlcine  shonld  have  it8upon  the  shelves 
various  operations  connected  with  this  branch  of  0f  his  library,  and  the  student  will  find  it  a  superior 
medicine;  and  will  do  much  to  smooth  the  rngged  text-book.— ^»ciw»«H  Med.  Ke.ws,  Oct.  1S78. 
path  of  the  young  gvnajcoljgist  and  relieve  the  per-  . 

plexity  of  the  man  of  mature  vears.  —  Canadian  This  second  revised  edition,  of  course,  deserves  all 
Journ.  of  Med  Science  Nov.  1 S7S.  the  commendation  given  to  Its  predecessor,  with  the 

additional  one  that  it  appears  to  include  all  or  nearly 
We  pity  the  doctor  who,  having  any  consider-  all  the  additions  to  onr  knowledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of  L  have  beeu  made  since  the  appearance  of  the  first  edi- 
"  Barnes"  for  daily  consultation  and  instruction.  It  tlon  The  American  references  are,  for  an  English 
is  at  once  a  hook  of  great  learning,  research,  and  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  the  same  time  emi-  cordially  recommend  the  volume  to  American  read- 
nently  practical.  That  It  has  been  appreciated  by  ers — Journ.  of  Nervous  and  Mental  Disease,  Oct. 
the   profession,  both   in   Great   Britain   and  in  thie    1878. 

country,  is  shown  by  the  second  edition  following  Thig  Becond  editlon  0f  Dr.  Barnes's  great  work 
so  soon  upon  the  irst.-Am.  Practitioner,  INov.  come8  t0  U8  containing  mauyaddltlons  and  improve- 
,S78-  meats  which  bring  it  up  to  date  in  every  feature. 

Dr.  Barnes's  work  is  one  of  a  practical  character,  The  excellences  of  the  work  are  too  well  known  to 
largely  illustrated  from  cases  in  his  own  experience  require  enurnerstion,  and  we  hazard  the  prophecy 
but  by  no  means  confined  to  such,  as  will  he  learned  that  they  wi  I  for  many  years  maintain  its  high  po- 
from  the  fact  that  he  quotes  from  no  less  than  628  altlon  as  a  standard  text-book  and  guide  book  for 
medical  authors  in  numerous  countries.  Coining  studen's  and  practitioners. —  Ar.  C.  Med.  Journ., 
from  such  an  author.  It  Is  not  necessary  to  say  tbat    Oct   1878 


o 


'HAD  WICK  [JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE   DISEASES  PEfTJLTAR  TO  WOMEN.    In  one 

neat  volume,  royal  12tno.,  with  illustrations.     (Preparing.) 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Diu.of  Women).      23 
IPMMET  {THOMAS  ADDIS),  M.D. 

■*-*  Surgeon  to  the  Woman' s  Hospital,  New  Tork,et«. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNAECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.  Second  Edition.  Thorougly  Revised. 
In  one  large  and  very  handsome  octavo  volume  of  875  pages,  with  133  illustrations. 
Cloth,  $6;   leather,  $6  ;  half  Russia,  $6  50.      (Just  Ready.) 

Preface  to  the  Second  Edition. 
The  unusually  rapid  exhaustion  of  a  large  edition  of  this  work,  while  flattering  to  the  author 
as  an  evidence  that  his  labors  have  proved  acceptable,  has  in  a  great  measure  heightened  his 
sense  of  responsibility.  He  has  therefore  endeavored  to  take  full  advantage  of  the  opportunity 
afforded  to  him  for  its  revision.  Every  page  has  received  his  earnest  scrutiny;  the  criticisms 
of  his  reviewers  have  been  carefully  weighed  ;  and  while  no  marked  increase  has  been  made  in 
the  size  of  the  volume,  several  portions  have  been  rewritten,  and  much  new  matter  hos  been 
added.  In  this  minute  and  thorough  revision,  the  labor  involved  has  been  much  greater  than 
is  perhaps  apparent  in  the  results,  but  it  has  been  cheerfully  expended  in  the  hope  of  rendering 
the  work  more  worthy  of  the  favor  which  has  been  accorded  to  it  by  the  profession. 


In  no  country  of  the  world  has  gynecology  re- 
ceived moreattention  th-+n  in  America.  It  is,  then, 
with  a  feeling  of  pleasure  that  we  welcome  a  work 
on  diseases  of  women  from  so  eminent  a  gynaecolo- 
gist as  Dr.  Emmet,  and  the  work  is  essentially  clini- 
cal, and  leaves  a  strong  impress  of  the  author's  in- 
dividuality. To  criticize,  with  the  care  it  merits, 
the  book  throughout,  would  demand  far  more  space 
than  is  at  our  command.  In  paring,  we  can  say 
that  the  work  teems  with  original  ideas,  fresh  and 
valuable  methods  of  practice,  and  is  written  in  a 
clear  and  elegant  style,  worthy  of  the  literary  repu- 
tation of  the  country  of  Longfellow  and  Oliver  Wen- 
dell Holmes.—  Brit.  Med.  Journ.,  Feb.  21, 18S0. 

No  gynaecological  treatise  has  appeared  which 
contains  an  equal  amount  of  original  and  useful 
matter;  nor  does  the  medical  and  surgical  history 
of  America  include  a  book  mors  novel  and  useful. 
The  tabular  and  statistical  information  which  it 
contains  is  marvellous,  both  in  quantity  and  accu- 
racy, and  cannot  be  otherwise  than  invaluable  to 
future  investigators.     It  is  a  work  which  demands 


not  careless  reading  but  profound  study.  Its  value 
as  a  contribution  'o  gynaecology  is,  perhaps,  greater 
than  that  of  all  previous  literature  on  the  subject 
combined. — Chicago  Med   Gaz.,  April  H,  1880 

The  wide  reputation  of  the  author  makes  its  pub- 
lication an  event  in  the  gynascological  world  ;  and 
a  glance  through  its  pages  shows  that  it  is  a  work 
to  be  studied  with  care.  ...  It  must  always  be  a 
work  to  be  carefully  studied  and  frequently  con- 
sulted by  those  who  practise  this  branch  of  our  pro- 
fession.— Lond.  Med.  Times  and  Gaz  ,  Jan.  10, 18S0. 

The  character  of  the  work  is  too  well  known  to 
require  extended  notice — suffice  it  to  say  that  no 
recent  work  upon  any  subject  has  attained  such 
great  popularity  so  rapidly.  Asa  work  of  general 
reference  upon  the  subjact  of  Diseases  of  Women  it 
is  invaluable.  As  a  record  of  the  largest  clinical 
experience  and  observation  it  has  no  equal.  No 
physician  who  pretends  to  keep  up  with  the  ad- 
vances of  this  department  of  medicine  cau  afford  to 
be  without  it. — Nashville  Journ.  of  Medicine  and 
Surgery,  May,  1880. 


nUNCAN  {J.  MATTHEWS),  M.D.,  LL.D.,  F.R.S.E.,  etc. 

CLINICAL    LECTURES    ON    THE    DISEASES   OF   WOMEN, 

Delivered  in  Saint  Bartholomew's  Hospital.     In  one  very  neat  octavo  volume  of  173 

pages.  Cloth,  $1  60.  (Just  Ready.) 
They  are  in  every  way  worthy  of  their  author  ;  )  The  author  is  a  remarkably  clear  lecturer,  and 
indeed,  we  look  upon  them  as  among  the  most  valu- 1  his  discussion  of  symptoms  and  treatment  is  full 
ab  e  of  his  contributions  They  are  all  upon  mat-  |  and  suggestive.  It  will  be  a  work  which  will  not 
ters  of  great  interest  to  the  general  practitioner,  j  fail  to  be  read  with  benefit  by  practitioners  as  well 
Some  of  them  deal  wilh  subjects  that  are  not,  as  a  '  as  by  students.  —  Pliila.  Med.  and  Surg.  Reporter, 
rule,  adequately  handled  in  the  text-books ;  others!  Feb.  7,1880. 

of  them,  while  bearing  upon  topics  that  are  usually  |  We  have  rea(j  thi8  book  with  a  great  deal  of 
treated  of  at  length  in  such  works,  yet  bear  such  a  ;  pleasure  It  is  fall  of  good  things.  The  hints  on 
stamp  of  individuality  that,  if  widely  read,  as  they  ]  patnology  and  treat  meat  scattered  through  the  book 
crtainly  deserve  to  be,  they  cannot  fail  to  exert  a  i  are  aoaaat  trustworthy,  and  of  great  value.  A 
wholesome  restraint  upon  the  undue  eagerness  with  .  healthy  scepticism,  a  large  expetience,  and  a  clear 
which  many  young  physicians  seem  bent  upon  fol-  ,  judgment  are  everywhere  manifest.  Instead  of 
lowing  the  wild  teachings  which  so  infest  the gy use-  bristliDg  with  advice  of  doubtful  value  and  un- 
cology  of^the   present   day.— N.  T.    Mad.   Journ.,  ;  B0Utld  character,  the  book  is  in  every  respect  a  safe 

I  guide. — The  London  Lancet,  Jan.  21,  1880. 


March,  1880. 


t>AMSBOTHAM  [FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  Keating,  M.  D., 
Professor  of  Obstetrics,  «fec,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  Iiree 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  oontaiDing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00 


TU'INCKEL  (F.), 

'  '  Professor  and  Director  of  the  Gynaecological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  James  Rkad  Chadwick,  M.D.  In 
one  octavo  volume.     Cloth,  $4  00.      (Lately  Issued.) 


JiAXNER  {THOMAS  H.),  M.D. 

ON  THE  SIGNS  AXD  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  oloth,  $4  25. 


24         Henry  C.  Lea's  Son  &  Co.'s  Publications — {Midwifery). 

PLAYFAIR  (  W.  S.),  M.D.,  F.R.C.P., 
Profetsor  of  Obstetric  Medicine  in  King's  College, etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Third  American  edition,  revised  by  the  author.  Edited,  with  addition?,  by  Robert  P. 
Harris,  M.D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  nearly  2C0 
illustrations.     Cloth,  $4  ;  leather,  $5  ;  half  Russia,  $5  50.     {.Just  Ready.) 

EXTRACT    FROM    THE    AUTHORS    PREFACE. 

The  second  American  edition  of  my  work  on  Midwifery  being  exhausted  before  the  corre- 
sponding English  edition,  I  cnnnot  better  show  my  appreciation  of  the  kind  reception  my  book 
has  received  in  the  United  States  than  by  acceding  to  the  publisher's  request  that  I  should 
myself  undertake  the  issue  of  a  third  edition.  As  little  more  than  a  year  hag  elapsed  since 
the  second  edition  was  issued,  there  are  naturally  not  many  changes  to  make,  but  I  have, 
nevertheless,  subjected  the  entire  work  to  careful  revision,  and  introduced  into  it  a  notice  of 
most  of  the  more  important  recent  additions  to  obstetric  science.  To  the  operation  of  gastro- 
elytrotomy — formerly  described  along  with  the  Caesnrean  section — I  have  now  devoted  a  sepa- 
rate chapter.  The  editor  ot  the  Second  American  edition,  Dr.  Harris,  enriched  it  with  many 
valuable  notes,  of  which,  it  will  be  observed,  I  have  freely  availed  myself. 

The  medical  profession  baa  now  the  opportunity  i  a  very  intelligent  idea  of  them,  yet  all  details  not 
of  adding  to  their  stock  of  standard  medical  works  |  necessary  for  i  fnll  understanding  of  the  subject  are 
one  of  the  best  volumes  on  midwifery  ever  published.  |  omitted. — Cincinnati  Med.  News,  Jan.  1880. 
The  subject  is  taken  up  with  a  master  hand.  The  |  The  rapidity  with  which  one  edition  of  this  work 
part  devoted  to  laborin  all  its  various  presentations,  fon0ws  another  is  proof  alike  of  its  excellence  and 
the  management  and  results,  is  admirably  arranged,  (  of  the  estimate  that  the  profession  has  formed  of  it. 
and  the  views  entertained  will  be  found  essentially  (  ,t  u  ln(leed  g0  well  known  and  so  highly  valued 
modern,  and  the  opinions  expressed  trustworthy  ,  tha,  nothing  need  be  said  of  it  as  a  whole.  All 
The  work  abonnds  with  plates,  illustrating  various  j  thlogfl  cons  dered,  we  regard  this  treatise  as  the  very 
obstetrical  positions;  they  are  admirably  wrought,  |  beKt  on  Midwifery  in  the  English  language.—  N.  T. 
and  afford  great  assistance  to   the  student.—^.  0.     MeAical  Journal,  May   1880 

Med.  and  Surg.  Journ.,  March,  1880.  T»         .  .   i      i  .    .    .,  ... 

,     .,  *        ,     '  .  ,  It  certainly   is  an  admirable  exposition  of  the 

If  inquired  of  by  a  medical  student  what  work  on  Scienc-i  and  Practice  of  Midwifery.  Of  course  the 
obstetrics  we  should   recommend  for  him,  as    par    additions  made  by  the  American  editor,  Dr.  R.  P 


excellence,  we  wonld  undoubtedly  advise  him  to 
choose  Playfair's.  It  is  of  convenient  size,  but  what 
is  of  chief  importance,  its  treatment  of  the  various 
subjects  is  concise  and  plain.  While  the  discussion* 
and  descriptions  are  sufficiently  elaborate  to  render 


Harris,  who  never  ntters  an  idle  word,  and  whose 
studious  researches  in  some'special  departments  of 
obstetrics  are  so  well  known  to  the  profession,  are 
of  great  value  — The  American  Practitioner,  April, 
1880. 


T>ARNES  {FANCOURT),  M.D., 

-*-*  Physician  to  the  General  Lying-in  Hospital,  London. 

A  MANUAL  OF  MIDWIFERY  FOR  MIDWIYES  AND  MEDICAL 

STUDENTS.     With  50  illustrations.     In  one  neat. royal  12mo.  volume  of  200  pages; 

cloth,  $1  25.     {Now  Ready.) 
The  book  is  written  in  plain,  and  as  far  as  pos-     will  be  popular  with  those  for  whom  it  has  been 
sible  in  nntechnical  language.  Any  intelligent  mid-    prepared.    The  examining  questions  at   the   back 
wife  or  medical  student  can  easily  comprehend  the    will  be  found  very  useful. —  Cincinnati  Med.  A'etos, 
directions.     It  will  undoubtedly  fill  a  want,  and     Aug.  1£79. 


/THE  OBSTETRICAL  JOURNAL.     {Free  of  post  age  for  1880.) 

THE  OBSTETRICAL  JOURNAL  of  Great  Britain  and  Ireland; 
Including   Midwifery,  and  the  Diseases  of  Wosii  aid  Infants.     A  monthly  of 
64  octavo  pages,  very  handsomely  printed.     Subscription,  Three  Dollars  per    annum 
Single  Numbers.  25  cents  each. 
With  the  January  nnmber  will  terminate  Vol.  VII.  of  the  Obstetrical  Journal.     The  first 
No.  of  Vol.  VIII.  will  be  issued  about  Feb.  1st;  the  "American  Supplement"  of  16  pages 
per  No.  will  be  discontinued,  and  the  periodical  will  thenceforth  consist  of  64  pages  per  number, 
at  the  exceedingly  low  price  of  Three  Dollars  per  annum,  free  of  postage.     For  this  trifling 
f  utn  the  subscriber  will  thus  obtain  more  than  750  pages  per  annum,  containing  an  extent  and 
variety  of  information  which  may  be  estimated  from  the  fact  that  Vol.  VI.  of  the  "Obstetri- 
cal Journal"  contains  in 

Original  Communications     .     .      44  Articles  I  In  Monthly  Summary,  Gynbcic        28Articles 
Hospital  Practice      ....        4      "  "  •«  Pediatric     4 

Genkral  Correspondence    .     .        5      "  News 

Reviews  of  Books 9      " 

Proceedings  of  Societies  .  .  101  " 
In  Monthly  Summary,  Obstetric  73  " 
and  that  it  numbers  among  in  contributors  the  distinguished  names  of  Lombe  Atthill,  J.  H. 
Avki.isg,  Robert  Barnes,  J.  Henry  Bknnet,  Natha*  Bozeman,  Thomas  Chambers,  Fleet- 
wood Churchill,  Charles  Clay,  John  Clay,  J.  Matthews  Duncan,  Arthur  Farre,  Robert 
Oreenhalgh,  W.  M.  Qraily  Hewitt,  J.  Braxton  Hicks,  William  Leishman,  Angus  Mac- 
donald,  Alfred  Meadows,  Alex.  Simpson,  J.  G.  Swayne,  Lawson  Tait,  Edward  J.  Tilt, 
E.  H.  Trenholme,  T.  Spencer  Wells,  Arthur  Wigglesworth,  and  many  other  distin- 
guished practitioners.  Under  such  auspices  it  has  amply  fulfilled  its  object  of  presenting  to 
the  physician  all  that  is  new  and  interesting  in  the  rapid  development  of  obstetrical  and  gynae- 
cological science. 

As  a  very  large  increase  in  the  subscription  list  is  anticipated  under  this  reduction  in  price, 
gentlemen  who  propose  to  subscribe,  and  subscribers  intending  to  renew  their  subscriptions, 
are  recommended  to  lose  no  time  in  making  their  remittances,  as  the  limited  number  printed 
may  at  any  time  be  exhausted. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Midwifery,  Surgery).    25 


T  EISHMAN  (  WILLIAM),  M.D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  Ac. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Third  American  edition,  revbed  by 
the  Author,  with  additions  by  John  S.  Parky,  M.D.,  Obstetrician  to  the  Philadelphia 
Hospital,  Ac.  In  one  large  and  very  handsome  octavo  volume,  of  733  pages,  with  over 
two  hundred  illustrations.  Cloth,  $4  50;  leather,  $5  50  ;  half  Russia,  $6.  {Just  Ready.) 
Few  works  on  this  subject  have  met  with  as  great  j  riorin  the  English  language.— Canada  Lancet,  Jan. 
a  demand  as  this  one  appears  to   have.    To  judge  j  1680. 

by  the  frequency  with  which  its  author's  views  are  j  The  book  is  greatly  improved,  and  as  such  will  be 
quoted,  and  its  statements  referred  to  In  obstetrical:  welcomed  by  those  who  are  trying  to  keep  posted  in 
literature,  one  would  judge  that  there  are  few phy-|  tne  rapiQ  advances  which  are  being  made  in  the 
siclans  devoting  ranch  attention  to  obstetrics  who  I  „tndy  of  obstetrics.— Boston  Med.  aitd  Surg  Journ., 


are  without  it.     The  author  is  evidently  a  man  of 
ripe  experience  and  conservative  views,  and  in  no 
branch  of  medicine  are  these  more  valuable  than  in 
this. — New  Remedies,  Jan.  1880. 
We  gladly  welcome  the  new  edition  of  this  excel 


Nov    S7,  1879. 

To  the  American  stndent  the  work  before  us  must 
prove  admirably  adapted,  complete  In  all  its  parts, 
essentially  modern  in  its  teachings  and  with  dem- 
onstrations noted  for  clearness  and  precision,  it  will 


lent  textbook  of  midwifery.  The  former  editions  l  gain  jn  faV0r  and  be  recognized  as  a  work  o^  stand- 
have  been  most  favorably  received  by  the  protes-  j  ard  merit.  The  work  cannot  fail  to  be  popular,  and 
sion  on  both  sides  of  the  Atlantic.  In  the  prepara-i  jg  COrdially  recommended.— N.  0.  Med.  and  Surg. 
tion  of  the  present  edition  the  author  has  made  such  j  ^ourn)  March,  18S0. 

alterations  as  the  progress  of  obstetricil  science]  irishman's  is  certainly  one  of  thebest  systematic 
seems  to  require,  and  we  cannot  but  admire  ll\G  j  work*  on  midwiiery.  It  is  very  complete  in  all  the 
ability  with  which  the  task   has  been  performed. ,  g  eiHenMal  for  „neh  a  treati>e.     To  practitioners 

We  consider  it  an  admirable  text-book  for  students,  ^  glndentg  u  lg  t0  be  gtr0Ilg,T  recommended  as  a 
during  their  attendance  upon  lectures,  and  nave|safe  ftnd  reliable  gtlide  to  the  modern  practice  of 
great  pleasure  in  recommending  it.  As  an  exponent  i  mjdwlrery-._0anada  Med.  and  Surg.  Journal, 
of  the  midwifery  of  the  present  day  it  has  no  snpe-  j  Marcj,  jggo. 

pARRV  (JOHN  S.),  M.D.,  ~ 

■*-  Obstetrician  to  the  Philadelphia  Hospital,  Vice-Prest.  of  the  Obstet.  S  ^ciety  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,   PROGNOSIS,  AND   TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  60.     {Lately  Issued.) 

TJODGE  {HUGH  L.),  M.D., 

•*"*■  Emeritus  Professor  of  Midwifery,  Ac,  in  the  University  of  Pennsylvania,  Ac. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.    In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 
The  work  of  Dr.  Hodge  is  something   more  than     oody  in  a  iingle  volume  the  whole  science  and  art  of 
a  simple  presentation  of  his  particular  views  in  the    Obstetrics.     An  elaborate  text  is  combined  with  ac- 
dejartment   of  Obstetrics;    it  is   something  more     curate  and  varied  pictorial  illustrations,  so  that  no 
than  an  >rdinarytreatiseonmidwifery;  it  is.infact,     fact   or  principle  is  left  unstated  or  unexplained, 
a  cyclopedia  of  midwifery.     He  has  aimed  to  em-    —Am.  Med.  Times,  Sept.  3,  1864. 

#*#  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 

VTIMSON  {LEWIS  A.),  A.M.,  M.D., 

**J  Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  of  about  500pages,  with  332  illustrations  ;  cloth,  $2  50.  {Just  Issued.) 
The  work  before  us  is  a  well  printed,  profusely  performing  them.  The  work  is  handsomely  illus- 
lllu8trated  manual  of  over  four  hundred  and  seventy  |  trated,  and  the  descriptions  are  clear  and  well  drawn, 
pages.  The  novice,  by  a  perusal  of  the  work,  will  J  It  is  a  clever  and  useful  volume;  every  student 
gain  a  good  idea  of  the  general  domain  of  operative  ,  should  possess  one.  The  preparation  of  this  work 
surgery,  while  the  practical  surgeon  has  presented  !  does  away  with  the  necessity  of  pondering  over 
to  him  within  a  very  concise  and  intelligible  form  larger  works  on  surgery  for  descriptions  of  opera- 
the  latest  and  most  approved  selections  of  operative  j  tions,  as  it  presents  in  a  nut-shell  just  what  is  wanted 
procedure.  Theprecision  ard  conciseness  with  which  i  by  the  surgeon  without  an  elaborate  search  to  find 
the  different  operations  are  described  enable  the  I  it. — Md.  Med  Journal,  Aug.  1878. 
author  to  compress  an  immense  amount  of  practical  I  The  author>g  conciseness  and  the  repleteness  of 
information  in  a  very  small  compass.— N.  T.  Medical  I  the  work  with  vaiuable  illustrations  entitle  it  to  be 
Record,  Aug.  3, 18i8.  |  ciaggea  wjtn  the  text-books  forstudents  of  operative 

This  volume  is  devoted  entirely  to  operative  sur-  j  surgery,  and  as  one  of  reference  to  the  practitioner. 
gery,  and  is  intended  to  familiarize  the  student  w:th  j  — Cincinnati  Lancet  and  Clinic,  July  27, 1878. 
the  details  of  operations  and  the  different  modes  of  | 


SKEY'S  OPERATIVE  SURGERY.  In  1  vol.  8vo. 
el.,  of650  pages  ;  withabout  lOOwood-cuts  $3  26 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
Practice  of  Suroert.  In  lvol.  Svo  cl'h,750p.  $2. 

GIBSON'SINSTITUTES  AND  PRACTICE  OF  SUR- 
GERY. Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp., leather,  raised  bands.  $6  50. 

THEPRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  William  Pirrie.F.R.S  E.,  Profes'r  of  Surgery 
in  the  University  of  Aberdeen.    Edited  by  Jobs 


Neill,  M.D.,  Professor  of  Surgery  in  the  Penna. 
MedicalCollege,Surg'n  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  $3  75. 

MILLER'S  PRINCIPLESOF  SUKGERY.  FourthAme- 
rican.  from  the  Third  Edinburgh  Edition.  In  one 
lar^e  8vo.  vol.  of  700  pages,  with  340  illustrations, 
cloth,  $3  75. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Kdition  Revised  by 
the  American  editor.  In  onelargeSvo.  vol.  of  nearly 
700  pages,  with  304  illustrations:  cloth,  $3  76. 


26 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


SIR  OSS  (SAMUEL  D.),  M.D., 

^~*  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OP    SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.   Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.   Fifth  edition 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15;  half  Russia, 
raised  bands,  $16. 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
th«  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  tc  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  nearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very 
moderate  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind 
ing  render?,  it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly 
belonging  to  the  iomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 

We  have  now  brought  our  task  to  a  conclusion,  and 
have  seldom  read  a  work  with  the  practical  value  ot 
which  we  have  been  more  impressed.  Kvery  chapter  is 


so  concisely  put  together,  that  the  busy  practitioner, 
when  in  difficulty,  ran  at  once  find  tbeinformation  he 
requires.  His  work,  on  the  contrary,  is  cosmopolitan, 
the  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical, that  it  is  almost  a  false  compli- 
ment to  say  that  we  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surgery  is  the 
practice  of  surgeons.  The  printingaud  binding  of  the 
work  is  unexceptionable;  indeed.it  contrasts,  in  the 
latter  respect,  remarkably  with  English  medical  and 
surgical  cloth-hound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re-binding  before 
they  are  any  time  in  use. — Dub.  Journ.  of  Med.  Sci.. 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  "ele- 
phant."there  has  been  roomforconsiderableadditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Land.  Lancet, Nov.  16,1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 


edition  of  Gross's  "Surgery,"  will  confirm  his  title  of 
•'  Primus  inter  Pares."  Ft  is  learned,  scholar-like,  n>e- 
thodical,  precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  socompleteand  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — N.Y. 
Med.  Journ.,  Feb.  1878. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — St. 
Louis  Medicaland  Surg.  Journ., Oct.  1872, 

The  two  magnificent  volumes  before  us  afford  a  very 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor. and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitionersdesirousofenrichingtheirlibrary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancet  and  Observer,  Sept.  ls-72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  a  scientific  account  of  surgical  theory 
and  practicein  all  its  departments. — Brit,  and  for. 
M'd  Chir.Rev.,  Jan.  1873. 


B] 


»F  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE   ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  Samuel  W.  Gross,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  ot  574  pages,  with  170  illus- 
trations: cloth,  $4  50.  (Just  Issued.) 
For  reference  andgeneral  information,  the  physician  leases  of  the  urinary  organs. — Atlanta  Med.  Journ.,  Oct. 
orsurger.n  can  find  noworkthat  meets  their  necessities  j  1876. 

more  thoroughly  than  this,  a  revised  edition  of  an  ex- 1  It  ig  with  pieagure  we  now  agRin  take  up  this  old 
cellent  treatise,  and  no  medical  library  should  be  with-  ^^  Jn  ^  de(,idedlv  new  drefi!.  Indeed>  it  must  be  re. 
out  it.  Replete  with  handsome  illustrations  and  good  garded  ag  a  new  book  in  Tery  many  of  itg  part8>  The 
ideas,  it  has  the  unusual  advantage  of  being  easily  chapters  on  "Diseases  of  the  Bladder,"  "Prostate 
comprehended,  by  the  reasonable  and  practical manner  Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
in  which  the  various  subjects  are  systematized  and  I -ie^orlpti v-e  writing;  while  the  chapter  on  "Stricture' 
arranged  We  heartily  recommend  it  to  the  profession  |  ig  one  of  the  most  concise  and  clear  that  we  have  ever 
„cavaluableadditlontotheimport*ntliteratureofd!f-|read ,_jv>tc  York  Mid.  Journ., Nov.  1876. 

rif  THE  SAME  AUTHOR. 

A  PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN   THE 

AIR-PASSAGES.     In  1  vol.  8vo.,  with  illustrations,  pp.  468,  cloth,  $2  75. 

T)RUITT  (ROBERT),  M.R.C.S.,£c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illus- 
trated with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octai  o 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire  —Dublin  Quarterly  Journal. 

It  Is  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr  Drnitt 'shook,  though  containingonly  some 
seven  hundred  pages,  both  the  principles  and  the 


practice  of  surgery  are  treated,  and  so  clearly  and 
perspicuously,  as  to  elucidatee  very  important  topic. 
We  nave  examined  thebook  mostthoroughly,  and 
can  lay  that  thissuccessis  well  merited.  His  book 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  and 
classified  and  of  being  written  in  a  style  at  once 
clear  md  succinct. — Am.  Journal  of  Med.  Science?. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery).  27 

TJAMILTON  (FRANK  H.)  M.D.,  LL.D. 

-*--*-  Surgeon  to  the  Bellevne  Hospital,  New  York. 

A  PRACTICAL  TREATISE  ON  FRACTURES  AND  PISLOCA- 

TIONS      Sixth  edition,  thoroughly  revised,  and  much  improved.     In  one  very  handsome 
octavo  volume  of  over  900  pages,  with  352   illustrations.     Cloth,  $5  50;    leather,  SO. 50; 
half  Russia,  raised  bands,  $7  00. 
The  demand  which  has  so  speedily  exhausted  five  large  editions  of  this  work,  shows  that  the 
author    has  succeeded  in  supplying  a  want,  felt  by  the  profession  at  large,  of  an   exhaustive 
treatise  on  a  frequent  and  troublesome  class  of  accidents.     The  unanimous  voice  of  the  profes- 
sion abroad,  as  well  as  at  home,  bat  pronounced  it  the  most  complete  work  to  which  the  surgeon 
can  refer  for  information  respecting  the  details  of  the  subject.     In  the  preparation  of  this  new 
edition,  the  author  has  added  a  chapter  on  General  Prognosis:  that  on  Fractures  of  the  Patella 
has  been  entirely  rewritten,  in  order  that  the  results  of  a  recent  exhaustive  study  of  this  sub- 
ject might  be  given,  and,  in  fact,  the  entire  matter  of  the  book  has  undergone  most  thorough 
revision.      A  number  of  illustrations  have  been  omitted  to  make  place  for  new  ones,  and  a  few 
have  been  inserted  from  the  German  edition,  published  at  Gottingen  in  1877. 
A  few  notices  of  the  previous  edition  are  appended. 

The  volume  before  us  is  iwe  say  it  with  a  pang  of    a  single  complete  treatise  on  Fractures  and  Disloca- 
wounded  patriotism)  the  be<t  and  handiest  book  on     lions  in  the  English  language.     It  has  remained  for 
the  subject  in  the  English  laiguage.     It  is  in  vain    our  American  brother  to  produce  a  complete  treatise 
to  attempt  a  review  of  it ;  nearly  as  vain  to  seek  j  upon  the  subject. — London  Lancet. 
for  auy  sins,  either  of  commission  or  omission. — 


Edinburgh  Med.  and  Surg.  Journal. 
From  the  great  labor  and  time  bestowed  upon  its 


As  everyone  knows,  tlis  is  the  most  complete  and 
reliable  work  on  the  subjects  of  which  it  treats  pub- 
lished in  any  language,  not  even  excepting  Mal- 


P-eparationT  we  had  been  led  to  anticipate  a  very  *a,*ne  "  e*cellen'  »n<l  standard  treatise.  Hence 
thorough  and  elaoorate  monograph,  and  an  atten-  »t  would  be  a  waste  of  time  and  space  further  to 
live  perusal  of  its  pages  has  satisfied  us  thai  our  attempt  to  convince  our  readers  of  its  excellences, 
expectations  have  been  fully  realised.  The  work  \  "  rem,a!ns  °°ly  l0'  U8Kt0  a<*?  that'*°  eve,7  r«sPuc| 
is  by  far  the  most  complete  disquisition  on  fractures  tl'i«  flftli  edition  has  been  thoroughly  revised,  and 
and  dislocations  in  the  Eig  ish  language.  It  is  not  '  contains  some  fifty  pages  of  new  matter  more  thau 
our  intention  to  present  anything  like  a  formal  ,  tbe  fourth  edition.- la.  Med.  Monthly,  Jan.  187«. 
analysis  of  this  work  ;  to  do  so  would  carry  us  far  ■  For  thoroughness,  for  completeness  of  detail,  and 
beyond  the  limits  which  we  have  assigned  to  us,  to  j  for  clearness  of  illustration,  this  work  is  without 
say  nothing  of  the  fact  that  it  would  be  a  matter  of  '  its  equal— without  a  rival  indeed— in  its  depart- 
supererogition,  inasmuch  as  no  intelligent  practi-  ;  merit  of  the  medical  literature  of  our  language.  Its 
tioner  will  be  likely  to  be  without  a  copy  of  it  for  ;  value  is  enhanced  by  the  artistic  skill  displayed  in 
ready  use.  No  library,  however  extensive,  will  be  •  the  mechanical  execution  of  the  volume. — Pacific 
complete  without  it  — North  American  Medico-  Med.  and  Surg.  Joitrn.,  Jan.  1876. 
Chirurgical  Rtviiw.  There  is  no  better  work  on  tbe  subject  in  exis- 

This  is  a  valuable  contribution  to  the  surgery  of  |  tence  than  that  of  Dr.  Hamilton.  It  should  be  in  the 
mosc  important  affections,  and  is  the  more  welcome,  I  possession  of  every  general  practitioner  and  sur- 
inasmuch  as  at  the  present  lime  we  do  not  possess  t  geon — The  Am.  Journ.  of  Obstetrics,  Feb.  1S76. 

A  SHHURST  (JOHN,  Jr.),  M.D., 

•£*-  Prof,  of  Clinical  Surgery,  Dhiv  of  Pa.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition,  enlarged  and  revised.  In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illustrations.  Cloth,  $6;  leather,  $7;  half  Russia,  $7.50  (Jn»t 
Ready.) 


Conscientiousness  and  thoroughness  are  two  very 
marked  traits  of  character  in  the  author  of  this 
book.  Out  of  these  traits  largely  has  grown  the 
success  of  his  mental  fruit  in  the  past,  and  the  pre- 
sent offer  seems  in  no  wise  an  exception  to  what  has 
gone  before.  The  general  arrangement  of  the  vol- 
ume is  the  same  as  in  the  first  edition,  but  every  part 
has  been  carefully  revised,  and  much  new  matter  j 
added.— Phila.  Med.  Times,  Feb.  1,  1S79. 

We  have  previously  spoken  of  Dr.  Ashhnrst's 
work  in  terms  of  praise.  We  wish  to  reiterate  those 
terms  here,  and  to  add  that  no  more  satisfactory 
representation  of  modern  surgery  has  yet  fallen 
from  the  press.  In  point  of  judicial  fairness,  of: 
power  of  condensation,  of  accuracy  and  conciseness 
of  expression  and  thoroughly  good  English,  Prof. 
Ashhurst  has  no  superior  amongthe  surgical  writers 
in  America. — Am.  Practitioner,  Jan.  1S79. 

The  attempt  to  embrace  in  a  volume  of  1000  pages  i 
the   whole  field   of   surgery,   general   and   special,  j 
would  be  a  hopeless  task  unless  through  the  most 
tireless  industry  in  collating    and   arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 
edition  to  the  latest  date.    Of  course  this  book  is  not 
desigued  for  specialists,  but  as  a  course  of  general 
surgical  knowledge  and    for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  surpassed  I 
by  any  that  has  yet  appeared,  whether  of  home  or  j 
foreign    authorship.— N.    Carolina    Med.   Journal, 
Jan.  1879. 


Ashbur-it's  Surgery  is  too  well  known  in  this 
country  to  require  special  commendation  from  us. 
This,  its  second  edition,  enlarged  and  thoroughly 
revised,  brings  it  nearer  our  idea  of  a  model  text- 
book than  any  recently  published  treatise.  Though 
numerous  additions  have  been  made,  the  size  of  the 
work  is  not  materially  increased  The  main  trouble 
of  textbooks  of  modern  times  is  that  tbey  are  too 
cumbersome.  The  student  needs  a  book  which  will 
furnish  him  the  most  information  in  the  shortest 
time  In  every  respect  this  work  of  Ashhurst  is 
the  model  textbook-  full,  comprehensive  and  com- 
pact.— Nashville  Jour,  of  Med.  and  Surg.,  Jan.  '79. 

The  favorable  reception  of  the  first  edition  is  a 
guarantee  of  the  popularity  of  this  edition,  whieh  is 
fresh  from  the  editor's  hands  with  many  enlsrge- 
ments  and  improvements.  The  author  of  this  work 
is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  can 
only  add  that  the  work  is' well  arrang.  d,  filled  with 
practical  matter,  and  contains  in  brief  and  clear 
language  all  that  is  necessary  to  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  his  daily  routine 
practice. — Md.  Med.  Journal,  Jan.  1879. 

The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
uiie,  speaks  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dents and  physicians.— Cincin.  Med.  News,  Jau.  '79. 


28 


Henry  C.  Lea's  Son  &  Co.'s  Publications — (Surgery). 


fi]  RICH  SEN  (JOHN  E.), 

Pro/e8tor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Snr- 

gical  Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition,  illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  Id  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  ;  leather,  $10  50;  half  Russia,  $11  50.     (Now  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  science  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  pages  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seventh  edition  is  before  the  world  as  the  last  i 
word  ot  surgical  science.  There  may  be  monographs 
which  excel  it  upon  certain  points,  bat  as  a  con- 1 
spectus  upon  surgical  principles  and  practice  it  is 
unrivalled.     It  will  well  reward  practitioners   to 
read  it,  for  it  Las  been  a  peculiar  province  of  Mr. 
Erichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science      We   need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend   the    work    to    students  that  they  may   be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  Invaluable  guide  at  the  bedside.—  Am.  Practi-\ 
tioner,  April,  1878. 

It  is  no  iile  compliment  to  say  that  this  is  the  best 
edition  Mr.  Erichsen  has  ever  produced  of  his  well-  i 
known  book.  Besides  inheriting  the  virtues  of  iis 
predecessors,  k  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
Into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly aver  that  we  know  of  no  other  single 
work  where  the  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  into  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.—  London  Lancet,  Feb.  14,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text-book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  one  hun- 
dred and  fifty  new  illustrations  have  been  inserted, 
including  qnite  a  number  of  microscopical  appear- 
ances of  pathol  jgieal  processes.  So  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Med.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Surgery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  none 
which  in  all  points  has  satisfied  us  so  well  as  the  classic 
treatise  of  Rricbsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  hisunsurpassed  grasp 
of  his  subject,  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  another  edi- 
tion.— Med.  and  Surg.  Reporter,  Feb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
lias  been  thoroughly  written  up,  and  not  merely  amend- 
ed by  a  few  extra  chapters.  A  great  improvement  has 
been  made  in  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawu.  The  author  highly  appreciates  the 
favor  wilh  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  bis  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has  succeeded  admirably,  must,  we  thiok,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — A'.  ¥.  Med.  Journal, 
Feb.  1878. 

Erichsen  has  stood  so  prominently  forward  for 
years  as  a  writer  on  Surgery,  that  his  repntation  is 
world  wide,  and  his  nam*  is  as  familiar  to  the  med- 
ical student  a*  to  the  accomplished  and  experienced 
surgeon.  The  work  is  not  a  reprint  of  former  edi 
tions,  but  has  in  many  places  been  entirely  rewrit- 
ten. Eecent  improvements  in  snrgery  have  not  es- 
caped his  notice,  various  new  operations  have  been 
thoroughly  analyzed,  and  their  merits  thoroughly 
discussed.  One  hundred  and  fifty  new  wood-cuts 
add  to  the  value  of  this  work. — N.  0.  Med.  and  Surg. 
Journal,  March,  1878. 


TJOLMES  (TIMOTHY),  M.D., 

■*-*-  Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE.    In  one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7  : 

half  Russia,  $7  50.     (Just  Issued.) 
This  is  a  work  which  has  been  lookedfor  on  both    Its  force  and  distinctness.—  JV.  T.  Med.  Record,  April 
•ides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes    14,  1876. 

is  a  surgeon  of  large  and  va'ried  experience,  and  one  It  wlu  be  fonnd  a  mogt  excellent  epitome  of  sur- 
of  the  best  known,  and  perhaps  the  most  brilliant  g8ry  by  the  general  practitioner  who  has  not  the 
writer  upon  surgical  subjects  in  England.  It  is  a  ume  togiveattentionto  more  minute  and  extended 
book  for  students— and  an  admirable  one— and  for  WOrksand  to  the  medicaUtudent.  In  fact,  weknow 
the  busy  general  practitioner.  It  will  give  a  student  of  no  one  we  can  more  cordially  recommend.  The 
all  the  knowledge  needed  to  pass  a  rigid  examina-  aothor  ha,  succeeded  well  in  giving  a  plain  and 
tlon.  The  book  fairly  justinesthe  high  expectations  practical  account  of  each  surgical  injury  and  die- 
that  were  formed  ofit.  Its  style  is  clear  and  forcible,  i  eage,  aDd  of  the  treatment  which  is  most  corn- 
even  brilliant  at  times,  and  the  conciseness  needed  I  moniT  advisable.  It  will  no  doubt  become  a  popu- 
to  bring  it  within  its  properlimits  has  not  impaired  i  iar  work  in  the  profession,  and  especially  as  a  text- 

I  book. — Cincinnati  Med.  News,  April,  1876. 


ASHTONONTHEDI8EASBS,  INJURIES,  akdMAL-i  SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 


FORMATIONS  OP  THE  RECTUM  AND  ANCS: 
with  remarks  on  Habitual  Constipation.  Second  I 
American,  from  the  fourth  and  enlarged  London  ' 
Edition.  With  Illustrations.  la  one  6vo.  vol.  of 
387  pages,  cloth ,$3  26. 


TIONS  OF  MINOR  SORCERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12ino.  vol.oIS83pagss  withl84  wood-cats  Cloth 
♦  175. 


Henry  C.  Lea's  Son  &  Co.'s  Publications— (Ophthalmology).      29 
DRY ANT  {THOMAS),  F.R.C.S., 

■*-*  Surgeon  to  Ouy's  Hospital. 

THE  PRACTICE  OF  SURGERY.  Third  American,  from  the  Sec- 
ond and  Revised  English  Edition.  Thoroughly  revised  and  much  improved,  by  John  B 
Roberts,  M.D.  In  one  large  and  very  handsome  imperial  octavo  volume  of  over  1050. 
pages,  with  672  illustrations,     (hi  Press) 

1XTELLS  (J.SOELBERG), 

"'  Professor  of  Ophthalmology  in  King's  College  Hospital,  Ac. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Third  London  Edition.  Thoroughly  revised,  with  copious  additions,  by  Chng. 
S.  Bull,  M  I). ,  Surgeon  and  Pathologist  to  the  New  York  Eye  and  Ear  Infirmary.  Illus- 
trated with  about  250  engravings  on  wood,  and  six  colored  plates.  Together  with  selec- 
tions from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  ana  very  handsome 
octavo  volume  of  900  pages.  Cloth,  $5 ;  leather,  $6;  half  Russia,  raised  bands,  $6.60. 
(Just  Ready. ) 

The  long-continued  illness  of  the  author,  with  its  fatal  termination,  has  kept  this  work  for 
some  time  out  of  print,  and  has  deprived  it  of  the  advantage  of  the  revision  which  be  sought 
to  give  it  during  the  last  years  of  hi-  life.  This  edition  has  therefore  been  placed  under  the 
editorial  supervision  of  Dr.  Bull,  who  has  labored  earnestly  to  introduce  in  it  all  the  advances 
which  observation  and  experience  have  acquired  for  the  theory  and  practice  of  ophthalmology 
since  the  appearance  of  the  last  revision.  To  accomplish  this,  considerable  additions  have  been 
required,  and  the  work  is  now  presented  in  the  confidence  that  it  will  fully  deserve  a  continu- 
ance of  the  very  marked  favor  with  which  it  has  hitherto  been  greeted  as  a  complete,  but  con- 
cise, exposition  of  the  principles  and  facts  of  its  important  department  of  medical  science. 

The  additions  made  in  the  previous  American  editions  by  Dr.  Hays  have  been  retained, 
including  the  very  full  series  of  illustrations  and  the  test-types  of  Jaeger  and  Snellen. 


N- 


'ETTLESHIP  [EDWARD),  F.R.C.S., 

Ophthalmic  Surg,  and  Leat.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital.  London. 

MANUAL    OF    OPHTHALMIC    MEDICINE.     In  one  royal  12mo. 

volume  of  over  350  poges,  with  89  illustrations.  Cloth,  $2.  (Just  Ready.) 
The  book  is  written  in  a  careful  and  logical  man- 1  It  is  multum  in  parvo,  containing  all  the  leading 
ner,  and  though  extremely  concise,  we  have  failed  points  to  be  remembered  in  the  pathology,  descrip- 
to  notice  any  evidence  of  ambiguity.  It  is  rendered  |  tion,  and  treatment  of  diseases  of  the  eye.  It  will 
more  compact  and  homogeneous  by  frequent  refer-  1  be  found  especially  valuable  in  preparing  for  exam- 
ences,  by  page  number,  to  other  portions  of  the  inations.  Practitioners  will  find  it  convenient  as  a 
work  ;  repetitions  are  thus  avoided,  and  we  have  I  work  of  reference,  when  they  wish  to  refresh  their 
been  surprised  to  find  how  much  information  our  I  memories  in  respect  to  the  features  of  some  affec- 
author  has  succeeded  in  conveying  in  so  small  a  I  tions. — Cincinnati  Med.  News,  Jan  ISSO. 
space.  A  careful  study  bf  the  book  will  well  repay  The  anthor  is  to  be  congratulated  upon  the  very 
the  general  practitioner,  even  though  it  sbould  !  guccessfui  manner  in  which  he  has  accomplished  his 
serve  only  as  a  monitor.  It  is  particularly  useful ;  tagk  .  he  hag  8ncceeded  in  being  concise  without 
in  the  latter  regard,  as  the  subject  of  treatment  i^  |  sttcrificlug  clearness,  and,  including  the  whole 
presented  in  a  thoroughly  conservative  wanner.-  i  grouDa  covered  by  more  voluminous  text-books, 
A.  r.  Med.  Record,  March  6,  IsSO.  |  flas  g-lveti  an  excellent  rtsvmi,  of  all  the  practical 

The  author  has  succeeded  in  touching  upon  about  !  information  they  contain.  We  do  not  hesitate  to 
all  the  points,  operations,  diseases  of  the  eye  in  j  pronounce  Mr  Nettleship's  book  the  best  manual  on 
relation  to  general  diseases,  and  has  prepared  a  very  }  ophthalmic  surgery  for  the  use  of  students  and 
acceptable  book. — Cincinnati  Lancet  and  Clinic,  "busy  practitioners"  with  which  we  are  acquain- 
Feb.  7,  IhSO.  |  ted.  -Am.  Jour.  Med.  Sciences,  April,  1880. 


(TARTER  (R.  BRUDENELL),  F.R.CS., 

*S  Ophthalmic  Surgeon  to  St.  George  s  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.  Edit- 
ed, with  test-types  and.  Additions,  by  John  Green,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  $3  76.  (Just 
Issued.) 

It  is  with  great  pleasure  that  we  can  endorse  the  work  [  chapter  is  devoted  to  a  discussion  of  the  uses  and  selec- 
as  a  most  valuable  contribution  to  practical  ophthal- 1  tion  ofspectaoles,  and  is  admirably  compact,  plain,  and 
mology.  Mr. Carter  neverdeviates  from  the  end  he  has  [  useful,  especially  the  paragraphs  on  the  treatment  of 
in  view,  and  presents  the  subjectin  aclear  and  concise  I  presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
manner,  easy  of  comprehension,  and  hence  the  more  j  due  the  author  for  many  useful  hints  in  the  great  sub- 
valuable.  We  would  especially  commend,  however,  as  iject  of  ophthalmic  surgery  aud  therapeutics,  afield 
worthy  of  high  praise,  the  manner  in  which  the  thera-  j  whereof  late  years  we  glean  but  a  few  grains  of  sound 
peutics  of  disease  of  the  eye  is  elaborated,  for  here  the  i  wheatfrom  a  mass  of  chaff. — New  York  Medical  Record, 
author  is  particularly  clear  and  practical,  where  othei  j  Oct.  23, 1S75. 
writers  are  unfortunately  too  often  deficient.  The  final  I 


B 


ROWNE  [EDGAR  A.), 

Surgeon  to  the.  Liv-.rpool  Eye  and  Ear  Infirmary,  and  to  the  Dispensary  for  Skin  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty-five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     (Now  Ready.) 

LAURENCE'S  HANDST  BOOK  OF  OPHTHALMIC  i  LAWSON'S  INJURIES  TO  THE  EYE,  ORBIT, 
SURGERY,  for  the  use  of  Practitioners.  Second  AND  ETELIDS:  their  Immediate  and  Remote 
edition,  revised  and  enlarged  With  numerous  Effects.  With  about  one  hundred  illustrations, 
illustrations.  In  one  very  handsome  octavo  vol-  In  one  very  handsome  octavo  volume,  cloth, 
ume,  cloth,  $2  75.  \      $3  60. 


30    Henry  C.  Lea's  Son  &  Co.'s  Publications — (Med.  Jurisprudence). 


T>URNETT  {CHARLES  H.),  M.A  ,  M.D., 

J-*  Aural  Surg  to  the  Presb.  Bosp.,  Surgeon-in-<harge  of  the  Infir  for  Dig.  of  the  Ear,  Phila. 

THE    EAR,   ITS    ANATOMY.   PHYSIOLOGY,  AND   DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.     In  one  hand- 
gome  octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  ;  leather, 
$5  50  ;  half  Russia,  $6  00.     (Now  Ready.) 
Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  wouldseem  to  render  desirable  a  new  work  in  which  all  the  re- 
sources of  the  most  advanced  science  should  be  placed  at  the  disposal  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  labors  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  department. 

Foremen  among  ihe  numerous  recent  contribu-  medical  student,  and  its  study  will  well  repay  the 
tions  to  sural  literatim  will  be  ranked  this  work  busy  practitionerin  the  pleasure  he  will  derive  from 
of  Dr.  Burnett.  It  is  impossible  to  do  justice  to  the  agreeable  style  in  which  many  otherwise  dry 
this  volume  of  over  600  pages  in  a  necessarily  brief  and  mostly  unknown  subjects  are  treated.  To  the 
notice.  It  mast  suffice  to  add  that  the  book  is  pro-  specialist  the  work  is  of  the  highest  value,  and  his 
fusely  and  accurately  illustrated,  the  references  are  sense  of  gratitude  to  Dr.  Burnett  will  we  hope,  be 
conscientiously  acknowledged,  while  the  result  has  proportiouate  to  the  amount  of  benefit  lie  can  obtain 
been  to  produce  a  treatise  which  will  henceforth  from  the  careful  study  of  the  book,  and  a  constant 
rank  with  the  classic  writings  of  Wilde  and  Von  reference  to  its  trustworthy  pages. — Edinbut  gh 
Tr&lsch.—  The  Loud.  Practitioner,  May,  1879.  Med.  Jour.,  Aug.  1678. 

On  account  of  the  great  advances  which  have  been  ..  The  book  U  designed  especially  for  the  use  of  fu- 
made of  late  years  in  otology,  and  of  the  increased    dents  and  general  practitioners,  and  places  at  their 

ujouu    v.     .  j  9j  ,  rfuni^ku       Allien      VH     n'jh    a   mj     nfiu  ttm-h     >.    l.A.t^     a« 


disposal  much  valuable  material.  Such  a  book  as 
the  present  one,  we  think,  haslongbeen  needed, and 
we  may  congratulate  the  author  on  his  success  in 
filling  the  gap.  Both  student  and  practitioner  can 
study  the  work   with  a  great  deal  of  benefit.     It  is 


interest  manifested  in  it,  the  medical  profession  will 
welcome  this  new  work,  which  presents  clearly  and 
concisely  its  present  aspect,  whilst  clearly  indi- 
cating the  direction  in  which  further  researches  ran 
be  most  profitably  carried  on.     Dr.  Barn  tt  from  his 

own    matured  experience,  and  availing  himself  of ,  Pr.^fu,-ely  and   beautifully  illustrated.-^.  Y.  Mo*. 
the  observations  and  discoveries  of  others,  has  pro-  ]  Pital  <*azette,  Oct  15,  1877. 

duced  a  work,  which  as  a  text-book,  stands  facile  i  Dr.  Burnett  is  to  be  commended  for  having  written 
princeps  in  oar  language.  We  had  marked  several  ;  the  best  book  on  the  subject  in  the  Euglish  language, 
pa-sages  as  well  worthy  of  quotation  and  the  atten- '  and  especially  for  the  care  and  attention  he  lias 
tion  of  the  general  practitioner,  but  their  number  and  given  to  the  scientific  side  of  the  subject. — M.  Y. 
the  space  at  oar  command  forbid.  Perhaps  it  is  bet-  Med.  Journ.,  Dec.  1877. 
ter,  aa  the  book  ought  to  be  in  the  hands  of  every 


^AFLOR  (ALFRED    S.),M.D., 

Lecturer  on  Med.  Juriftp.  and  Chemistry  in  Ouy'a  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.     (Just  Issued.) 


The  present  is  based  upon  the  two  previous  edi- 
tions ;  ''butthecompleterevisiun  rendered  necessary 
by  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-legal  testimony  (and  what,  neis  nol?),sothat 


beihg  described  which  give  rise  to  legal  investiga- 
tions.— The  Clinic,  Nov.  6,  1875. 

Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  this  volume,  stores  of  learning,  experience,  and 
practical  acquaiutance  with  his  subject,  probably  far 
beyoad  what  any  other  living  authority  ou  toxicol- 
ogy could  have  amassed  or  utilized,  lie  has  fully 
sustained  his  reputation  by  the  consummate  skill 


all  that  U  required  to  be  known  about  the  present  and  legal  acuraen  be  hag  displayed  in  the  arrange- 
book  is  that  the  author  has  kept  it  abreast  with  the  menl  of  tne  8abject-matler,  and  the  result  is  a  work 
times.  What  makes  t  now,  as  always,  especially  ,  ou  Poisons  which  will  be  Indispensable  to  everv  stu- 
valuable  to  the  practitioner  is  its  conciseness  anu  dentor  practitionerin  lawand  medicine  -The' Dub- 
practical  character,  only  those  poisonous  substances  ,  Un  journ,  0j  Had.  Sei.,  Oct.  1876. 

V Y  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE.     Eighth  American  Edition.  Edited 

by  Johh  J.  Kkk.sk,  M.D.,  Prcf   of  Med.  Jurisp.  in  the  Univ.  of  Penn.     In  one  large 
octavo  volume  of  nearly  900  pages.     (In  Press.)  y 

To  the  members  of  the  legal  and  medical  profes-  best  authority  on  this  specialty  inourlaugnage.  On 
•  ion,  It  is  unnecessary  to  say  anything  commenda-  I  thispolnt,  however,  we  will  r-ay  that  weconsider  Dr. 
tory  of  Taylor's  Medical  Jurisprudence  We  might  j  Taylor  to  be  the  safest  medico-legal  authority  tofol- 
as  well  undertake  to  speak  o(  the  merit  of  Chitty's  low,  in  general,  with  which  we  are  acquainted  in  any 
Pleadings.—  Chicago  Legal  A'* tea,  Oct.  16,  1873.        llanguage.—  Va.  Clin.  Record,  Nov.  1873. 

It  Is  beyond  question  the  most  attractive  as  well       *i.i.i..,.jui r.\.    >*  ■•  i.  •..      i    ■ 

a.  most  reliable  manual  of  medical  jurisprudence       ThUlas  edition  of  the  Manual  Isprobablythebest 
iTi  i Vii,  it,.  t..n.i,i j_    r  i   ofall,  as  It  contains  more  material  andls  worked  nn 

9r^hitooravhv  °^'h,^g  ge"Jmy°ttrna^tu'n«'^''i«'^ftbeauthorase3,pre.sediBth. 
of  Syphilography,  Oct.  1878  ,a8t  edmon  of  ^  Prlne,   ,„_    0r   R  lhe  edU(,r 

[ttsaltogethersupernuousforustoofferanything  of  the  Manual,  has  done  everything  to  make  his 
inbehalfofa  workon  medicaljurlsprudence  by  an  workacceptable  to  his  medical  countrymen.  —A  Y 
aathorwholsalmostunlversally  esteemed  tobethe    Med.  Record,  Jan.  15,1874. 

T>Y  THE  SAME  AUTHOR. 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 
DENCE. Second  Edition,  Revised,  with  numerous  Illustrations.  In  two  large  octavo 
volumes,  cloth,  $10  00;  leather,  $12  00 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  mostauthoritativetreatise  on 
e.'ery  department  of  its  important  subject.  In  l:iying  it,  in  its  improved  form,  before  ibe  Amer- 
ican profeesion.  the  publi.-heis  trust  that  it  will  assume  the  same  position  in  this  country 


Henry  C.  Lea's  Son  <fe  Co.'s  Publications — (Miscellaneous).       31 


ROBERTS  (  WILLIAM),  M.D., 

J-*1  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE   ON  URINARY  AND  RENAL  DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  oases  and  engravings.  Third 
American,  from  the  ThirdRevised  and  Enlarged  London  Edition.  In  one  largt  and 
handsome-octavo  volume  of  over  600  pnges.     Cloth,  $4.     (Just  Ready.) 

THOMPSON  (SIR  HENRY), 

•*  Surgeon  and  Professor  of  Olinica  I  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  Issued.) 

T>Y  THE  HAMS  AUTHOR.  

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
(Lately  Published.) 

/PUKE  {DANIEL  HACfK),  M.D., 

J-  Joint  author  of  "  The  Manual  of  Psychological  Medicine,"  Ac. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416 pages,  cloth,  $3  25.  (Lately  Issued .) 

J>LANDFORD  (G.  FIELDING),  M.D.,  F.R.G.P., 

J-*  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Ac. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  Isaac  Ray,  M.  D.  In  one  very 
handsome  octavo  volume  of  471  pages  ;  cloth,  $3  25. 

It  satisfies  a  want  which  must  have  been  sorely 
felt  by  the  busy  general  practitioners  of  this  country. 
It  takes  the  form  of  a  manual  of  clinical  description 


of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  givingit  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varietiesof  insanity  as 


actually  seen  in  practice  and  the  appropriate  treat- 
ment for  them*  we  find  in  Dr.  Blandford's  work  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
)idinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extendsjinany  other. — London 
Practitioner,  Feb.  1871. 


f  EA  {HENRY  C). 

SUPERSTITION   AND   FORCE:    ESSAYS   ON  THE   WAGER   OF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Third  Revised 
and   Enlarged  Edition.    In  one  handsome  royal  12mo.  volume  of  552  pages.     Cloth, 
$2  50.     (Just  Ready.) 
This  valuable  work  is  in  reality  a  history  of  civi-  i  more  accurate  than  either  of  the  preceding,  but, 

lization  as  interpreted  by  the  prcgress  of  jnrispru- |  from  the  thorough  elaboration   is  more  like  a  har- 

dence.  ...     In  "Superstition  and  Force"  we  have 

a  philosophic  survey  of  the  long  period  intervfning 

between  primitive  barbarity  and  civilized  eulight- 

enment.     There  is  not  a  chapter  in  the  work  that 

should  not  be  most  carefully  studied,  and  however 

weM   versed    the  reader  may  be  in   the  science  of 

jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume  of  which    he   was   previously   ignorant.     The 

book  is  a   valuable   addition   to  the   literature  of 

social  science.—  Westminster  Review,  Jan.  1SS0. 


The  appearance  of  a  new  edition  of  Mr.  Henry  C. 


monious  concert  and  less  like  a  batch  of  studies. — 
The  Nation,  Aug.  1,  1878. 

Many  will  be  tempted  to  say  that  this,  like  the 
"DeclineandFall,"isone  of  theuncriticizable  books. 
Its  facts  are  innumerable,  its  deductions  simple  and 
inevitable,  and  its  chevaux-de-frise  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assault.  The  author  is  no 
polemic.     Though   he  obviously  feels  and   thinks 


Lea's  "Superstition  and  Force"  is  a  sign  that  our  j  strongly,    he   succeeds    in    attaining    impartiality. 
highest  scholar*  hip  is  not  without  honor  in  its  u<t      Whetl  er  looked  on  as  a  picture  or  a  mirror,  a  work 
tire  country.    Mr.  Lea  has  met  every  fresh  demand  I  such   as    this    has   a   lastiag   value. — Lippincott's 
for  his  work  with  a  careful  revision  of  it,  and  the  I  Magazine,  Oct.  1S78. 
present  edition  is  not  only  fuller  and,  if  possible,  | 


B 


T  THE  SAME  AUTHOR.    (Late'y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT-OF  CLERGY— EXCOMMUNICATION.  In  one  large 
royal  !2mo.  volume  of  516  pp.;  cloth,  $2  75. 


The  story  was  never  told  more  calmly  or  with 
greater  learning  or  wiser  thought.  We  doubt,  indeed, 
if  any  other  study  of  this  field  can  be  compared  with 
this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Mr.  Lea's  latest  work,1'  Studiesin  Church  History," 
filly  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which 


has  a  peculiarimportance  for  the  English  student,  and 
is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  can  hardly  pass  from  our  mention  of  such 
works  as  these — with  which  that  on  "Sacerdotal 
Celibacy"  sshonld  be  inclnded — without  noting  the 
literary  phenomenon  that  the  head  of  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenaum,  Jan.  7, 1S71. 


32 


Henry  C.  Lea's  Son  &  Co.'s  Publications. 


INDEX   TO    CATALOGUE. 


FAUB 

American  Journal  of  the  Medical  Sciences       .      1 
Allen's  Anatomy 7 


Anatomical  Atlas,  by  Smith  and  Horner 

Ashton  on  the  Rectum  and  Anus 

Attfield's  Chemistry    . 

Ash  well  on  Diseases  of  Females 

*  kshhurst's  Surgery      .        .        . 

Browne  on  Ophthalmoscope  . 


Browne  on  the  Throat 19 

•Burnett  on  the  Bar 30 

•iarnes  on  Diseatesof  Women    ...        .22 

Barnes'  Midwifery 24 

Bellamy's  Surgical  Anatomy       ....  7 

Bryant' s Practice  of  Surgery      ....  29 

Bloxam'e  Chemistry 11 

Blandford  on  Insanity 31 

Basham  on  Renal  Diseases 19 

Bartholow  on  Electricity 18 

Barlow's  Practice  ol  Medicine    ....  14 

Bowman's  (John  E.)  Practical  Chemistry.        .  9 

•  Bristowe's  Practice 1 


•  Bumsiead  on  Venereal 20 

Bimstead  and  Cullerier'sAtlasof  Venereal  .  20 
•Carpenter's  Human  Physiology  .        .      8 

Carpenter  on  the  Use  and  Abuse  of  Alcohol       .    12 

•Cornil  and  Ranvler 14 

Carter  on  the  Eye 29 

Cleland's  Dissector 7 

Classen's  Chemistry 9 

Clowes'  ChemUtry 11 

Century  of  American  Medicine  ....  5 
Chadwick  on  Diseases  of  Women  .  .  .22 
Charcot  on  the  Nervous  System  .  .  .  .18 
Chambers  on  Diet  and  Regimen  .  .  .  ■  19 
Chritstison  and  Griffith's  Dispensatory  .  .  12 
Churchill's  System  of  Midwifery        .  .     21 

Churchill  on  Puerperal  Fever  .  •  .  .  .21 
Condie  on  Diseases  of  Children  .  .  .  .21 
Cooper's  (B.  B.)  Lectures  on  Surgery         .  25 

Cullerier's  Atlas  of  Venereal  Diseases  .  .  20 
Cyclopedia  of  Practical  Medicine  •  .  .19 
Duncan  on  Diseases  of  Women    .        .        .        .23 

•  Dalton's  Human  Physiology      ....      9 

Davis's  Clinical  Lectures 15 

Deweee  on  Diseases  of  Females  .        .        .        .21 

Druitt's  ModernSurgery 26 

•Duoglison's  Medical  Dictionary  ...  4 
Bills' s  Demonstrations  in  Anatomy      ...       7 

•  Erichsen's  System  of  Surgery  .  .  .  .28 
•Emmet  on  Diseases  of  Women  .  .  .  .23 
Farquharson's  Therapeutics  ....     12 

Foster's  Physiology S 

Fenwick's  Diagnosis 14 

Flnlayson's  Clinical  Diagnosis  ....  18 
Flint  on  Respiratory  Organs        ....     19 

Flint  on  the  Heart 19 

Flint's  Practice  of  Medicine 15 

Flint's  Essays 15 

•Flint's  Clinical  Medicine  .  .  .  .  .15 
Flint  on  Phthisis 19 

19 
16 
16 
10 
is 
U 
n 

9 
U 

14 

ft 


Flint  on  Percussion 

Fothergill's  Handbook  ofTreatment  . 

Fothergill's  Antagonism  of  Therapeutic  Agents 

Fjwnes's  Elementary  Chemistry 

Fox  on  Diseases  of  the  Skin         . 

Fuller  on   the  Lungs,  Ac 

Green's  Pathologjand  Morbid  Anatomy  . 
Greene's  Medical  Chemistry 

Gibson's  Surgery 

Gluge's  Patho.oglcal  Histology,  by  Leidy 
•Gray's  Anatomy.. 


Galloway's  Analysis 9  i 

Griffith's  (R.  E.)  Universal  Formulary        .        .12' 

Gross  on  Urinary  Organs 26 

Gross  on  Foreign  Bodies  in  Air-Passages  .        .     2« 
•  Jross's  System  of  Surgery  .  .     26  j 

Habershon  on  the  Abdomen 16  j 

•Hamilton  on  Dislocations  and  Fraetnref  .        .     27 
Hartsborne's  Essentials  of  Medicine  .  .     15  j 

Hartsnome's  Conspectus  of  the  Medical  Sciences   6 
HarUhorne's  Anatomy  and  Physiology     .        .8, 
Hamilton  on  Nervous  Diseases    .        .        .        .     18  | 
Heath's  Practical  Anatomy  .         .        .         .6 

Hoblyn's  Medical  Dictionary     .        .        .        .41 


PAei 

Hodge  on  Women  .  .        .21 

Hodge's  Obstetrics        ...'...     26 
Holland's  Medical  Notes  and  Reflections  .       .     14 

•Holmes's  Surgery 28 

Holden's  Landmarks  6 

Horner's  Anatomy  and  Histology     ...      7 

Hudson  on  Fever 19 

Hill  on  Venereal  Diseases   .  .     20 

Hilller's  Handbook  of  Skin  Diseases  .        .     19 

Jones  (C.  Handfleid)  on  Nervous  Disorders     .     18 
Knapp's  Chemical  Technology   .  .     11 

Lea's  Superstition  and  Force  .        .        .31 

Lea's  Studies  in  Church  History         .        .        .31 

Lee  on  Syphilis 20 

•Leishman's  Midwifery 25 

La  Roche  on  Yellow  Fever 14 

19 

29 

1» 

9 

9 

6 

19 

2 

IS 

2\ 

25 

25 

21 

29 

6 

24 

25 

14 

11 

25 

24 

7 

17 

16 

31 

23 

9 

21 

4 

28 

21 

19 

28 

7 

25 

19 

7 

21 
7 
19 
21 
12 
13 
15 
14 
6 
23 
30 
80 
30 
31 
22 
31 
31 
14 
16 
19 
15 
29 
20 
20 
20 
19 
7 
19 
9 


La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye       ... 

Lehmann's  Physiological  Chemistry ,  2  vols 

Lehmann's  Chemical  Physiology 

Ludlow's  Manual  of  Examinations 
|  Lyons  on  Fever    .... 
j  Medical  News  and  Abstract 
|  Morris  on  Skin  Diseases 
;  Meigs  on  Puerperal  Fever   . 

Miller's  Practice  of  Surgery 
;  Miller's  Principles  of  Surgery    . 

Montgomery  on  Pregnancy 

Nettleship's  Ophthalmic  Medicine 

Neill  and  Smith's  Compendium  of  Med.  Science 

Obstetrical  Journal 

Parry  on  Extra-Uterine  Pregnancy 

Pavy  on  Digestion 

•Parrish's  Practical  Pharmacy   . 

Pirrie's  System  of  Surgery  . 

•Playfair's  Midwifery  . 

Quain  and  Sbarpey's  Anatomy,  by  Leidy 

•Reynolds'  System  of  Medicine  . 

Richardson's  Preventive  Medicine 

Robertson  Drinary  Diseases 

Ramsbotbam  on  Parturition 

Remsen's  Principles  of  Chemistry 

Rigby's  Midwifery 

Rodwell's  Dictionary  of  Science  . 

Stimson's  Operative  Surgery 

Swayne's  Obstetric  Aphorisms    . 

Seiler  on  the  Throat 

Sargent's  Minor  Surgery 

Sharpey  and  Quain's  Anatomy,  by  Leidy 

Skey's  Operative  Surgery 
Slade  on  Diphtheria 

Schafer's  Histology 

•Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomlca 

Smith  (Edward)  on  Consumption 

Smith  on  Wasting  Diseases  in  Cbildre 

•Stmt's  Therapeutics    . 

•Stille  A  Maisch's  Dispensatory 

Stnrgee  on  Clinical  Medicine 

Stokes  on  Fever    . 

Tanner's  Manual  of  Clinical  Medicine 

Tanner  on  Pregnancy   .... 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med   Jurisp 

Taylor  on  Poisons 

Tuke  on  the  Influence  of  the  Mind 

•Thomas  on  Diseases  of  Females 

Thompson  on  Urinary  Organs 

Thompson  on  Stricture  . 

Todd  on  Acute  Diseases 

Woodbury's  Practice     . 

Walshe  on  the  Heart    . 

Watson's  Practice  of  Physic 

•Wells  on  the  Bye 

West  on-Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

Williams  on  Consumption   . 

Wilson's  Human  Anatomy . 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wohler's  Organic  Chemistry 

Wlnckel  on  Childbed 23 


1  Atl 


Books  marked  *  are  also  bound  in  half  Russia. 


HENRY  C.  LEA'S  SON  &  CO.— Philadelphia. 


THE  LIBRARY 
UNIVERSITY  OF  CALIFORNIA 

Santa  Barbara 


THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
STAMPED  BELOW. 


3Sii5SII 


Series  9482 


«, 


i« 


V*ji 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


000122  842    8 


m^^H 


<-■■  •  > 1 1  HHBBH^H^HI^BiHiH 


I    1  J 


i  i  J 


>  ^BH  HB  BHHHB^H 

IHHHHHH 


hhHh 


l:l 


Ml HI I  $$$  HflHn 


>"*  si  "i*i<L  *'.">'^>?»*»  A>tiVij  V-^ltVi?; 


■>  XHnHH 


>$ '  '#M/i 7 'v»y  ■'• 


IHflflfl^HHBfl 


BraHNHBraa 

HHH^HHBH^HI 


